Centene Corporation

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

Grievance & Appeals Coordinator I

Director

• Oversee implementation of products and plans into Claims business units
• Ensure alignment with strategies and goals and consistency in implementation processes, methodology, and models
• Direct creation and maintenance of standard models for the claims implementation approach
• Manage all Claims and Configuration Operations functions during the implementation phase
• Provide strategic leadership and oversight of claims business implementation processes
• Manage adherence to standard implementation processes and collaborate on Business Requirements Document approvals with the Claims Process Owner
• Provide input into operating models, corporate functional and information system models, performance metrics, expected outcomes, and plan impacts
• Direct claims business implementations to meet budget, timeline, and scope requirements
• Provide input into business planning and develop timelines for New Health Plan Business Implementations

Director, Claims Business Implementation

• Analyze and resolve verbal and written claims and authorization appeals from providers
• Pursue resolution of formal grievances from members
• Gather, analyze, and report verbal and written 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
• Coordinate the Grievance and Appeals Committee as needed
• 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 documents, including copying, faxing, and scanning incoming mail
• Perform other duties as assigned

Manager

• Develop, assess, and coordinate holistic care management activities focused on members with significant mental/behavioral health needs
• Evaluate member service needs and develop or contribute to care plans/service plans
• Educate members, families, and caregivers about available services and benefits
• Evaluate complex and high-risk members and recommend plans of care
• Act as liaison and member advocate between members/families, physicians, and facilities/agencies
• Support members with mental/behavioral health needs, including serious mental illness, substance use disorder, self-injurious behavior, and psychiatric admissions
• Perform frequent home and other site visits, including up to 75% monthly travel for home visits
• Provide subject matter expertise and operational support for behavioral health activities, including crisis calls, mental health first aid, field safety, de-escalation, and medication monitoring
• Educate members on and coordinate medical, behavioral, and social community resources
• Coordinate service authorizations for services such as meals, employment, housing, foster care, transportation, and activities of daily living
• Coordinate referrals and help identify accessible providers, specialists, and community resources
• Maintain accurate documentation in the electronic care management system and ensure compliance with clinical and state/federal guidelines
• Provide leadership feedback on quality-of-care and service-delivery improvements
• Comply with all policies and standards and perform other assigned duties

LTSS Service Care Manager – Behavioral Health

• Develop, assess, and coordinate holistic care management activities for members with significant mental and behavioral health needs
• Evaluate member service needs and develop or contribute to care and service plans
• Educate members, families, and caregivers about services, benefits, treatment options, referrals, medications, preventive care, and provider instructions
• Evaluate complex and high-risk members and recommend plans of care
• Act as liaison and member advocate between members, families, physicians, facilities, and agencies
• Perform frequent home and other site visits, up to 75% monthly travel, to assess needs and collaborate with resources
• Provide subject matter expertise and operational support for behavioral health activities, including crisis calls, mental health first aid, field safety, de-escalation, and medication monitoring
• Educate on and coordinate medical, behavioral, and social community resources
• Coordinate service authorizations for services such as meals, employment, housing, foster care, transportation, and activities of daily living
• Make referrals and support identification of providers, specialists, and community resources
• Maintain accurate documentation in the electronic care management system and ensure compliance with clinical, state, and federal guidelines
• Provide leadership feedback to improve quality of care and cost-effective service delivery
• Comply with all policies and standards and perform other assigned duties

Program Manager

• Promote increased program efficiency, service levels, and value by monitoring performance and identifying improvement opportunities
• Plan, organize, monitor, oversee and lead multiple concurrent projects using cross-functional teams
• Identify opportunities to increase efficiency, improve service levels, and ensure regulatory compliance
• Develop improvement strategies and ensure organizational prioritization and resource alignment
• Manage projects through the full project life cycle, including requirements gathering, planning, resourcing, budgeting, execution, deployment and closure
• Translate contracts, regulatory requirements, business objectives, and leadership direction into clear scope, milestones, dependencies, ownership, and measurable outcomes
• Use approved AI, automation, dashboards, and Microsoft 365 tools to summarize information, identify patterns, prepare communications, and reduce repetitive administrative work
• Maintain project documentation, action items, issue lists, and risk mitigation plans
• Provide leadership and communicate project status to stakeholders through executive summaries and presentations
• Negotiate with stakeholders to secure resources, resolve issues, and mitigate risks
• Lead cross-functional meetings
• Provide functional and technical knowledge regarding program requirements and operations

Program Manager III

• Develop, assess, and coordinate holistic care management activities for members with significant mental/behavioral health needs
• Evaluate member service needs and develop or contribute to care plans and service plans
• Educate members, families, and caregivers on available services and benefits
• Evaluate complex and high-risk members and recommend plans of care
• Act as liaison and member advocate between members/families, physicians, and facilities/agencies
• Perform frequent home and other site visits, once a month or more, to assess needs and collaborate with resources
• Provide or facilitate education on preventive care, procedures, provider instructions, treatment options, referrals, medications, and healthcare benefits
• Provide subject matter expertise and operational support for behavioral health activities, including crisis calls, mental health first aid training, field safety, de-escalation, and medication monitoring
• Educate on and coordinate medical, behavioral, and social community resources
• Coordinate service authorizations for services such as meals, employment, housing, foster care, transportation, and activities of daily living
• Ensure appropriate referrals and identify accessible providers, specialists, and community resources
• Maintain accurate documentation in the electronic care management system
• Ensure compliance with clinical, state, and federal guidelines
• Provide leadership feedback on quality-of-care and service-delivery improvements
• Perform other assigned duties and comply with policies and standards

• Provide consultative support to providers to improve performance on member outreach, utilization management, cost, quality and risk
• Discuss, analyze and interpret performance reporting, member engagement data and other data resources to identify opportunities for improving member outcomes
• Interpret performance data, prioritize insights, and develop discussion and presentation documents
• Facilitate provider discussions regarding quality, utilization, cost, or risk performance improvement opportunities using corporate tools and reporting
• Collaborate with the health plan quality counterpart to ensure coordinated communication and goal alignment for provider discussions
• Develop proficiency in tools and value based performance (VBP) and educate providers on tool use and data interpretation
• Present detailed HBR (Health Benefits Ratio) analysis and create reports for Joint Operating Committee meetings
• Perform other duties as assigned
• Comply with all policies and standards

Provider Performance Specialist II

• Analyze portfolio data, documentation, and processes and consolidate information for reporting to senior leadership
• Collect, aggregate, and analyze portfolio management data using PMI standards, process and controls guidance, and project governance best practices
• Collaborate with program and portfolio managers to define reporting metrics and performance data, including financial and project-level performance
• Prepare detailed analytic packages for reporting and review by key stakeholders
• Participate in and lead workgroups designing and analyzing portfolio management and reporting
• Research leading practices for designing and implementing portfolio management standards
• Perform other duties as assigned

Portfolio Manager

Communications

• Provide communications and content marketing expertise for internal communications and content strategy
• Support the editorial cycle from creation to delivery for company written documents, communication and other content
• Support communication content delivered to large internal audiences online, via email and in live presentations, including all-employee audiences
• Write, review and revise emails, newsletters and promotional materials aligned with communication or marketing plans
• Manage the editorial process from creation to delivery with internal partners
• Identify and report on content-related metrics
• Design, review and revise department and partner/client content for accuracy, appropriateness, readability and brand adherence
• Create deliverables for internal-facing awareness, engagement, education and incentive initiatives
• Create artifacts and coordinate or deliver changes for internal websites
• Develop, implement and maintain associated internal media channels
• Order and track promotional items while ensuring budget compliance and reporting financial impact
• Develop and maintain professional relationships with printers, graphic artists and other vendors

Lead Communications Specialist

Marketing

• Develop and produce marketing materials
• Coordinate website changes
• Support implementation of the strategic public relations and communication plan
• Implement strategic communications plans and marketing initiatives supporting business development, brand management and competitive positioning
• Interface with Corporate Marketing & Communications Department to ensure branding and image consistency
• Lead large marketing and communication projects and initiatives
• Liaise with subsidiaries and perform day-to-day activities
• Develop annual marketing programs
• Write, design and produce brochures and other collateral
• Develop, coordinate and promote new healthcare initiatives
• Write and edit letters and other communication materials
• Develop and coordinate company website changes
• Develop promotional opportunities for health plans and specialty companies through health fairs and other events
• Support sales initiatives and create potential client outreach materials
• Plan for trade shows and conferences
• Comply with all policies and standards
• Perform other duties as assigned

Marketing Specialist

• Conduct routine and ad hoc provider network analysis by geography, specialty, and line of business
• Monitor network adequacy performance and identify potential gaps and access issues
• Lead monthly and quarterly Network Adequacy Committee meetings and develop supporting reporting materials
• Manage network gap remediation efforts through collaboration with Contracting, Provider Data Operations, Provider Engagement, Credentialing, Compliance, and Network Operations teams
• Prepare network adequacy reporting for internal leadership and regulatory requirements
• Support annual Medicaid and Medicare network adequacy exception request processes when applicable
• Perform provider network impact analyses related to contract negotiations, terminations, and network strategy initiatives
• Develop, maintain, and improve reporting tools, dashboards, trackers, business documentation, and process workflows
• Coordinate cross-functional workgroups and ensure action items are tracked through completion
• Serve as a subject matter resource for provider network composition, access, adequacy, and reporting
• Perform other duties as assigned
• Comply with all policies and standards

Program Manager II – Provider Network

Account Manager

• Maintain partnerships between the health plan and contracted provider networks
• Build client relations to ensure the highest level of care for members
• Engage providers on network performance opportunities and solutions
• Serve as primary provider contact and liaison with the health plan
• Triage and resolve provider issues with internal partners
• Respond to external provider-related issues
• Investigate, resolve, and communicate provider claim issues and changes
• Enter provider demographic information changes
• Educate providers on referrals, claims submission, website usage, EDI solicitation, and related topics
• 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

Provider Engagement Account Manager

Nurse

• Develop, assess, and coordinate care management activities based on member needs
• Develop or contribute to personalized care plans/service plans
• Educate members and families/caregivers on services, benefit options, care options, referrals, healthcare benefits, and provider instructions
• Evaluate member needs, barriers to care, available resources, and recommend/facilitate plans for best outcomes
• Identify providers, specialists, and community resources needed for care
• Provide psychosocial and resource support for access to local resources and services
• Coordinate between members/families/caregivers and care provider teams
• Monitor care plan goals and member status or changes in condition
• Collaborate with healthcare providers on care plan revisions and refer members for further evaluation
• Collect, document, and maintain member information and care management activities for regulatory compliance
• Perform on-site visits when appropriate
• Perform other duties as assigned and comply with all policies and standards

Care Navigator, LPN

• Collaborate with Quality, Health Services and Operations business owners or cross-functional work groups to develop and implement standards, policies, procedures, workflows, and decision support systems
• Oversee creation and implementation of programs supporting strategic initiatives in Health Services, clinical quality, and operational quality administration
• Design and facilitate programs, systems, workflows, and integration efforts aligned with corporate, market, contractual, regulatory, and quality requirements
• Serve as content and technical subject matter expert to operations managers and directors
• Develop detailed work plans, facilitate root cause analysis, identify and socialize process enhancements, set deadlines, assign responsibilities, and monitor and summarize project progress
• Lead state-required Performance Improvement Projects (PIPs), including topic selection, root cause analysis, implementation, and final submission
• Conduct needs assessments and ensure program teams and external stakeholders receive information timely
• Partner with Quality Analytics and Improvement Teams to determine data needs and assist in designing tools and reports
• Consult with clinical and operations staff and provide analysis services for patient quality-of-care improvement initiatives
• Conduct other responsibilities and duties as assigned
• Comply with all policies and standards

Grievance & Appeals Coordinator I

Director, Claims Business Implementation

Grievance & Appeals Coordinator I

LTSS Service Care Manager – Behavioral Health

LTSS Service Care Manager – Behavioral Health

Program Manager III

LTSS Service Care Manager – Behavioral Health

Provider Performance Specialist II

Portfolio Manager

Lead Communications Specialist

Marketing Specialist

Program Manager II – Provider Network

Provider Engagement Account Manager

Care Navigator, LPN

Quality Program Development Manager