Centene Corporation

Program Specialist

• Oversee implementation of assigned programs
• Lead development of program initiatives to improve and monitor service delivery and outcomes for assigned populations
• Develop and implement new programs, including project and work plans
• Execute program development efforts with provider and/or internal organizations
• Research industry trends and propose new programs and strategies
• Develop provider and/or internal training modules
• Develop and track outcome measures for specific populations
• Analyze and interpret outcome data and present findings to management
• Propose funding opportunities
• Direct cross-departmental teams implementing program development and improvement efforts
• Develop innovative solutions for treatment issues related to specific populations
• Represent the company in key community and State meetings related to specific populations
• Perform other duties as assigned
• Comply with all policies and standards

Program Specialist II

Care Coordinator

• Support the senior care management team and teams assigned to members
• Coordinate care to ensure services are delivered and continuity of care/member satisfaction is achieved
• Serve as a liaison among care managers, healthcare providers, community providers, partners, members, and caregivers
• Conduct member outreach by phone or home visits
• Discuss care plans/service plans, next steps, resources, questions, concerns, and ongoing education
• Coordinate care activities based on care/service plans and accommodate changes or progress
• Respond to member and provider inquiries, requests, and concerns
• Develop knowledge of care management services and respond to complex or escalated issues
• Communicate with care managers, practitioners, and others to facilitate member services
• Perform service assessments/screening for members with complex needs and document care needs
• Document and maintain member records in accordance with state and regulatory requirements
• Triage, adjust, and escalate complex requests to management
• Follow contractual, regulatory, and organizational standards and policies
• Provide education on benefits and available resources
• Assist with training and development needs
• Perform other duties as assigned

Care Coordinator III

Manager

• Leads or co-leads project-based efforts to drive operational efficiency through collaboration with the business and IT
• Applies prescriptive methodology using benchmarking, customer journey mapping, process flows, current state gap analysis, strategy mapping, financial optimization, organizational change management, and governance
• Manages and monitors key performance metrics and implements improvement plans
• Handles direct employee personnel issues and processes, including performance management, appraisal processes, development planning, and career pathing
• Supervises non-exempt direct reports, assigning workload, monitoring quality, and coaching associates
• Collaborates with internal teams and departments to educate them on the department and transfer social service inquiries
• Trains associates on new and existing processes
• Facilitates and participates in staff meetings
• Reviews, updates, and creates training materials
• Ensures business processes comply with state and federal guidelines
• Performs service organization research, data entry, and gap assignment/fulfillment
• Performs other duties as needed

Business Transformation Manager

Account Manager

• Maintain partnerships between the health plan and contracted provider networks
• Build client relations to ensure delivery of the highest level of care to members
• Engage providers on network performance opportunities and solutions
• Manage consultative account management and accountability for issue resolution
• Drive performance in contract incentives, quality, and cost utilization
• Serve as primary contact and liaison between providers and the health plan
• Triage provider issues to internal partners for resolution
• Receive and respond to external provider-related issues
• Investigate, resolve, and communicate provider claim issues and changes
• Enter provider-related demographic information changes
• Educate providers on referrals, claims submission, website usage, EDI solicitation, and related topics
• Conduct provider orientations and ongoing provider education
• Write and update orientation materials
• Manage network performance for assigned territory
• Evaluate provider performance and develop strategic improvement plans
• Drive improvement in Risk/P4Q, HBR, HEDIS/quality, cost, and utilization
• Complete special projects and other assigned duties

Provider Engagement Account Manager

Data Analyst

• Analyze health management programs, including data collection, validation, and outcome measurement
• Handle complex data requests, reports, and predictive data modeling
• Perform IRS, CMS, and HEDIS reporting
• Conduct internal data cleansing and data reconciliation analysis
• Perform trend analysis in various functional areas of health care management
• Create and generate reports through MS-Excel, MS-Access, and SQL using the Business Objects interface and direct links to core databases (ODS/EDW)
• Produce reports for and interface with senior management and internal and external stakeholders
• Gather and interpret business requirements and monitor data trends to proactively identify issues
• Execute data changes and update core systems as needed
• Handle multiple projects and timelines and communicate risks and issues to the manager regularly
• Assist with training lower-level Data Analysts
• Perform other duties as assigned
• Comply with all policies and standards

Data Analyst II, Python, R

• Assess and coordinate medical and supporting services across the continuum of care for complex/high-acuity populations
• Develop personalized care plans/service plans for long-term care members
• Evaluate service needs and recommend plans for optimal outcomes
• Collaborate with care management teams, healthcare providers, specialists, caregivers, and community resources
• Monitor member status, care-plan progress, complications, clinical symptoms, and changes in condition
• Review member data, referrals, and intake assessments to improve care quality and operating performance
• Coordinate member services, treatments, service authorizations, and community resources
• Collect, document, and maintain member information and care management activities
• Educate members and families/caregivers on disease processes, care gaps, care options, referrals, and benefits
• Act as liaison and member advocate between members/families, physicians, facilities, and agencies
• Perform home and other site visits as required
• Partner with leadership to improve quality and cost-effective service delivery
• May precept, coach, and support clinical new hires through onboarding and competency checkpoints
• Perform other duties as assigned and comply with policies and standards

Senior LTSS Service Care Manager, RN

Analyst

• Execute bulk claims automation requests using established procedures
• Validate automation eligibility and results
• Perform claims review, investigation, adjustment, and resolution for claims, appeals, inquiries, and payment discrepancies
• Support automation maintenance activities, including updates and configuration changes, with guidance
• Perform basic data validation and analysis using Excel and/or entry-level SQL
• Confirm automation outcomes and identify exceptions
• Assist in documenting workflows, job aids, and process steps
• Capture notes for current-state and proposed changes
• Correct identified errors
• Support requirements gathering by collecting inputs, clarifying operational needs, and documenting outcomes
• Respond to automation questions and issues from internal and external customers
• Escalate requests appropriately
• Participate in testing activities, including UAT support and regression checks
• Perform post-implementation validation
• Perform other duties as assigned
• Comply with all policies and standards

Business Automation Analyst I

• Act as a liaison with vendors and business partners to build strong, continuous relationships
• Understand business requirements, needs, and service expectations
• Maintain complex vendor relationships and enhance vendor experience
• Communicate with vendors to ensure member or provider satisfaction and performance
• Assess key performance data to monitor productivity and program compliance
• Build reports using performance data to identify process improvements
• Liaise between internal departments and vendors to handle escalations such as claims
• Facilitate new business and process implementations from launch through day-to-day interactions
• Seek new business opportunities with vendors to support compliance with standards and requirements
• Perform root cause analyses with vendors to identify business issues
• Liaise with workforce management and training teams to schedule and support vendor training
• Work with vendors on training, planned maintenance, and other services
• Perform other duties as assigned
• Comply with all policies and standards

Account Relations Manager II

• Perform care management duties to assess and coordinate medical and supporting services for complex/high-acuity populations
• Develop personalized care plans/service plans for long-term care members
• Evaluate service needs and recommend plans for optimal outcomes
• Coordinate members, families/caregivers, providers, specialists, and community resources
• Monitor care plans, member status, changes in condition, complications, clinical symptoms, and progress toward goals
• Assess potential entry into higher levels of care and/or waiver eligibility
• Review member data, referrals, and intake assessments to develop and improve care plans and operating performance
• Facilitate member services, treatments, service authorizations, and revised care plans
• Collect, document, and maintain member information and care management activities in compliance with regulations and guidelines
• Educate members and families/caregivers on disease processes, care gaps, provider instructions, care options, referrals, benefits, and community resources
• Act as liaison and member advocate between members/families, physicians, and facilities/agencies
• Conduct home and/or other site visits, potentially once a month or more, to assess member needs and collaborate with resources
• Partner with leadership to improve quality of care and cost-effective service delivery
• May precept and coach clinical new hires, support onboarding, and assess competency/readiness
• Perform other assigned duties and comply with all policies and standards

Senior RN, LTSS Service Care Manager

Attorney

• Learn about processes and functions within the Managed Care industry
• Develop professionally by contributing to projects that support the business
• Learn job functions and explore career opportunities within the Managed Care industry
• Apply academic knowledge and develop new skills through various projects
• Communicate project status and results to staff mentors and management
• Research legal, regulatory, and other topics within the functional area and industry
• Attend training and development presentations
• Perform other duties as assigned
• Comply with all policies and standards

Legal Intern, Graduate – Summer

• Perform care management duties for complex/high-acuity populations with primary medical/physical health needs
• Assess and coordinate medical and supporting services across the continuum of care
• Develop personalized care plans/service plans for long-term care members
• Evaluate service needs and recommend plans for optimal outcomes
• Continuously assess care plans and collaborate with care management teams, providers, specialists, and community resources
• Coordinate members, families/caregivers, and care provider teams to ensure appropriate person-centered care
• Monitor member status, complications, symptoms, changes in condition, and progress toward goals
• Review member data, referrals, and intake assessments to improve quality and develop care plans
• Collaborate with healthcare providers to facilitate services and treatments
• Collect, document, and maintain member information and care management activities
• Educate members and families/caregivers about disease processes, care gaps, provider instructions, care options, referrals, benefits, and community resources
• Act as liaison and member advocate between members/families, physicians, and facilities/agencies
• Coordinate service authorizations for services such as meals, employment, housing, foster care, transportation, and activities of daily living
• Conduct home and other site visits, potentially monthly or more often
• Partner with leadership to improve quality and cost-effective service delivery
• May precept and coach clinical new hires, support onboarding, and assess competency readiness
• Travel to member visits
• Perform other duties as assigned and comply with all policies and standards

Senior RN LTSS Service Care Manager

Clinician

• Perform reviews of members’ care and health status for Applied Behavioral Analysis services to determine medical appropriateness
• Monitor clinical effectiveness and efficiency of member care according to ABA guidelines
• Evaluate care before, during, and after ABA services for medical appropriateness and clinical standards
• Perform BH prior authorization reviews using ABA regulatory guidelines and criteria
• Analyze behavioral health member data to improve quality and appropriate service utilization
• Interact with behavioral health providers regarding level of care and services for members receiving ABA services
• Educate members and families about ABA and the behavioral health utilization process
• Provide leadership feedback on care improvement opportunities, process improvements, and new processes or policies
• Comply with all policies and standards and perform other assigned duties

Utilization Review Clinician – ABA

• Maintain partnerships between the health plan and contracted provider networks
• Build client relations to support the highest level of care for members
• Engage providers on network performance opportunities and solutions
• Manage consultative account management and accountability for issue resolution
• Drive performance in contract incentive performance, quality, and cost utilization
• Serve as primary contact and liaison between providers and the health plan
• Triage provider issues to internal partners for resolution
• Respond to external provider-related issues
• Investigate, resolve, and communicate provider claim issues and changes
• Initiate data entry for provider demographic information changes
• Educate providers on referrals, claims submission, website usage, and EDI solicitation
• Conduct provider orientations and ongoing education; write and update orientation materials
• Manage network performance for the assigned territory
• Evaluate provider performance and develop strategic improvement plans
• Drive improvement in Risk/P4Q, HBR, HEDIS/quality, cost, and utilization
• Complete special projects and other assigned duties
• Comply with all policies and standards

• Assess and coordinate medical and supporting services across the continuum of care for complex/high-acuity populations
• Develop personalized care plans/service plans for long-term care members
• Evaluate service needs and recommend plans for optimal outcomes
• Continuously assess care plans and collaborate with care management teams to identify providers, specialists, and community resources
• Coordinate between members, families/caregivers, and care provider teams
• Monitor member status, complications, clinical symptoms, care-plan progress, and changes in condition
• Review member data, referrals, and intake assessments to improve quality and develop appropriate care plans
• Collaborate with healthcare providers to facilitate services and treatments
• Collect, document, and maintain member information and care management activities
• Educate members and families/caregivers on disease processes, care gaps, care options, referrals, and healthcare benefits
• Act as liaison and member advocate between members/families, physicians, and facilities/agencies
• Coordinate community resources and service authorizations
• Conduct home and other site visits, including member assessments
• Partner with leadership to improve quality of care and cost-effective service delivery
• May precept and coach clinical new hires and support onboarding and competency readiness
• Travel for member visits and perform other assigned duties while complying with policies and standards

Senior LTSS Service Care Manager

General

• Analyze and resolve verbal and written claims and authorization appeals from providers
• Pursue resolution of formal grievances from members
• Gather, analyze, and report member and provider complaints, grievances, and appeals
• Prepare response letters for member and provider complaints, grievances, and appeals
• Maintain files on individual appeals and grievances
• May coordinate the Grievance and Appeals Committee
• Support pay-for-performance programs through data entry, tracking, organizing, and researching information
• Assist with HEDIS production functions, including data entry, calls to provider offices, and claims research
• Manage large volumes of documents, including copying, faxing, and scanning incoming mail
• Perform other duties as assigned
• Comply with all policies and standards

Program Specialist II

Care Coordinator III

Business Transformation Manager

Provider Engagement Account Manager

Data Analyst II, Python, R

Senior LTSS Service Care Manager, RN

Business Automation Analyst I

Account Relations Manager II

Senior RN, LTSS Service Care Manager

Legal Intern, Graduate – Summer

Senior RN LTSS Service Care Manager

Utilization Review Clinician – ABA

Provider Engagement Account Manager

Senior LTSS Service Care Manager

Grievance & Appeals Coordinator I