Centene Corporation

Clinician

• Perform clinical reviews and assess care related to mental health and substance abuse
• Monitor and determine whether levels of care and services are medically appropriate
• Evaluate member treatment before, during, and after services
• Perform prior authorization reviews in accordance with regulatory guidelines and criteria
• Perform concurrent reviews of behavioral health inpatient care, including treatment needs and discharge planning
• Analyze behavioral health member data to improve quality and utilization of services
• Educate providers, members, and families about the behavioral health utilization process
• Interact with behavioral health healthcare providers regarding level of care and services
• Engage with medical directors and leadership to improve care quality and efficiency
• Formulate and present cases in staffing and integrated rounds
• Comply with all policies and standards
• Perform other duties as assigned

Utilization Review Clinician – Behavioral Health

Supervisor

• Plan, coordinate, and control daily activities related to maintenance and repair of Fidelis Care New York vehicles
• Manage drivers and assist driving staff with requests as needed
• Coordinate schedules for the Fidelis Care Community Office Vehicles fleet of RVs
• Oversee fleet drivers across Upstate New York, including Rochester, Buffalo, Syracuse, and Albany
• Ensure RVs are properly maintained and safe for full operation
• Perform regular mechanical troubleshooting and maintain vehicle upkeep and cleanliness
• Call for maintenance and service to ensure ongoing fleet operation
• Plan and arrange travel schedules to minimize delays and ensure successful itineraries
• Coordinate vehicle presence at Marketing Events
• Ensure vehicles are stocked with current materials and brochures
• Determine optimum inventory and stock levels
• Reorder stock to control inventory levels and meet operational objectives
• Coordinate operations closely with the Marketing team

Supervisor, Community Relations Fleet

IT Support

• Understand the business and assist in prioritizing projects
• Audit project alignment with overall technical or business strategy
• Guide resource allocation and support project or program execution plans
• Manage Agile / Lean portfolios and support overall strategy, investment funding, Agile portfolio operations, and Lean governance
• Apply lean thinking to programs and products and coach stakeholders to achieve objectives
• Lead the development, management and optimization of portfolio, program, and project management methodologies and disciplines
• Manage portfolio strategy and analysis deliverables and processes
• Build partnerships within IT and various business units
• Facilitate portfolio management processes to ensure strategic alignment on technologies and goals
• Develop and execute portfolio change control, risk management and communications strategies
• Manage hiring and training of staff, conduct performance reviews, and provide leadership, technical guidance and coaching
• Share knowledge and develop staff capabilities
• Develop and communicate organizational objectives; inspire and motivate team members
• Perform other duties as assigned
• Comply with all policies and standards

Manager, IT Portfolio Management

Account Manager

• Maintain partnerships between the health plan and contracted provider networks serving communities
• Build client relations to ensure delivery of the highest level of care to members
• Engage providers to align on network performance opportunities and solutions
• Provide consultative account management and accountability for issue resolution
• Drive optimal performance in contract incentive performance, quality, and cost utilization
• Serve as primary contact for providers and act as liaison between providers and the health plan
• Triage provider issues for resolution with internal partners
• Receive and respond to external provider-related issues
• Investigate, resolve, and communicate provider claim issues and changes
• Initiate data entry of provider-related demographic information changes
• Educate providers regarding policies and procedures related to referrals, claims submission, website usage, EDI solicitation, and related topics
• Perform provider orientations and ongoing provider education
• Write and update orientation materials
• Manage network performance for assigned territory through a consultative/account management approach
• Evaluate provider performance and develop strategic plans to improve performance
• Drive provider performance improvement in Risk/P4Q, Health Benefit Ratio (HBR), HEDIS/quality, cost, and utilization
• Complete special projects as assigned
• Perform other duties as assigned
• Comply with all policies and standards

Provider Engagement Account Manager – Southern TX

• Perform clinical reviews and assess care related to mental health and substance abuse
• Monitor and determine whether levels of care and services are medically appropriate
• Evaluate member treatment before, during, and after services
• Perform prior authorization reviews in accordance with regulatory guidelines and criteria
• Perform concurrent reviews of behavioral health inpatient care, including treatment needs and discharge planning
• Analyze behavioral health member data to improve quality and utilization
• Educate providers, members, and families about the behavioral health utilization process
• Interact with behavioral health providers regarding levels of care and services
• Engage with medical directors and leadership to improve care quality and efficiency
• Formulate and present cases in staffing and integrated rounds
• Comply with all policies and standards
• Perform other duties as assigned

• Maintain strong, continuous relationships with vendors and business partners
• Understand business requirements, needs, and service expectations
• Work alongside vendor management team members to analyze key performance data and enhance vendor relationships
• Oversee and support strategy and coordination of work within the vendor management team
• Communicate with vendors to ensure member or provider satisfaction and quality performance
• Assess and analyze key performance data to monitor and measure productivity and program compliance
• Communicate insights from data using data storytelling
• Build and review reports to leverage key performance data, identify metrics, and find process improvement opportunities
• Act as a liaison between internal departments and vendors to handle escalations
• Represent the company or department in new business and process implementations from launch through day-to-day interactions
• Perform root cause analyses with vendors to identify business issues and problems
• Interface with quality assurance to improve member or provider experiences based on performance metrics and contractual obligations
• Liaise with workforce management and training teams to schedule and support vendor training
• Work directly with vendors on training, planned maintenance, and other services to educate and provide product or service updates
• Perform other duties as assigned

Senior Account Relations Manager

• Maintain partnerships between the health plan and contracted provider networks serving communities
• Build client relations to ensure delivery of the highest level of care to members
• Engage with providers to align on network performance opportunities and solutions
• Provide consultative account management and accountability for issue resolution
• Drive optimal performance in contract incentive performance, quality, and cost utilization
• Serve as primary contact for providers and liaison between providers and the health plan
• Triage provider issues for resolution with internal partners
• Receive and respond to external provider-related issues
• Investigate, resolve, and communicate provider claim issues and changes
• Initiate data entry of provider-related demographic information changes
• Educate providers on policies and procedures related to referrals, claims submission, website usage, EDI solicitation, and related topics
• Perform provider orientations and ongoing provider education, including writing and updating orientation materials
• Manage network performance for assigned territory through a consultative/account management approach
• Evaluate provider performance and develop strategic improvement plans
• Drive provider performance 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 – Northeast PA

• Act as a liaison with vendors and business partners to build strong, continuous relationships and understand business requirements, needs, and service expectations
• Work alongside vendor management team members to 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 and measure productivity of specific programs and program compliance
• Build reports using key performance data for metrics and process improvement identification
• Liaise between internal departments and vendors to handle escalations, including claims
• Represent the company/department in new business and process implementations from initial launch through day-to-day interactions
• Seek new business opportunities with vendors to create collaborative relationships supporting compliance with standards and requirements
• Perform root cause analyses with vendors to identify business issues and problems
• Liaise with workforce management and training teams to schedule and support vendor training
• Work directly with vendors on training, planned maintenance, and other services to educate and provide product/service updates
• Comply with all policies and standards
• Perform other duties as assigned

Account Relations Manager II

Analyst

• Direct the gathering and organization of assessment data and results to support risk reporting and monitoring
• Advise, design, and/or validate IT controls and processes
• Assist in designing corrective actions for control deficiencies
• Consult with control owners to implement controls that minimize or mitigate IT risks, vulnerabilities, and threats
• Ensure stakeholders incorporate new or updated controls into testing
• Administer and enhance ServiceNow IRM, including process flow development, record maintenance, workflow optimization, and data quality activities
• Collaborate within Agile teams and adapt to changing priorities in a sprint-based delivery model
• Work with IT stakeholders to understand business environments, processes, and procedures and maintain systems of controls across IT functions
• Assess enterprise-wide risk and compliance levels arising from external and internal threats
• Maintain departmental work processes for IT controls
• Interface with business control personnel and provide technical guidance
• Communicate, consult, and assist with remediation of control findings and gaps
• Develop or mature KRI and KPI metrics and deliver reports and presentations to management
• Determine cross-functional impacts or risks of proposed technology solutions and identify efficiency opportunities
• Manage stakeholders, issues, and risks
• Perform other assigned duties
• Comply with all policies and standards

Senior IT Assurance Analyst

• 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 with providers to align on network performance opportunities and solutions
• Provide consultative account management and accountability for issue resolution
• Drive optimal performance in contract incentive performance, quality, and cost utilization
• Serve as primary contact for providers and liaison between providers and the health plan
• Triage provider issues for resolution with internal partners
• Receive and respond to external provider-related issues
• Investigate, resolve, and communicate provider claim issues and changes
• Initiate data entry of provider-related demographic information changes
• Educate providers on referrals, claims submission, website usage, EDI solicitation, and related topics
• Perform provider orientations and ongoing provider education
• Write and update orientation materials
• Manage network performance for assigned territory through a consultative/account management approach
• Evaluate provider performance and develop strategic improvement plans
• Drive provider performance 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

General

• Identify, oversee, and manage coordination of member transitions in the community
• Support leadership in ensuring timely and safe transitions across healthcare service levels
• Coordinate care plans with community care coordinators
• Educate transition enrollees, members, families, and caregivers about services, requirements, limitations, and exclusions
• Perform or assist with member assessments and screenings
• Develop or assist with member transition, service, and care plans
• Identify newly enrolled members requiring transition services
• Ensure existing authorizations are honored and resolve transition issues with care management teams and providers
• Track transition metrics, identify trends and process improvements, and maintain documentation
• Draft education materials and resources
• Assist with education and training programs for care coordination staff and providers
• Evaluate member needs and available resources and facilitate optimal transition plans
• Coordinate members and families with care provider teams
• Interact with healthcare providers to facilitate care coordination
• Perform other assigned duties and comply with policies and standards

Transition Specialist

Program Manager

• Promote increased program efficiency, service levels, and value by capturing and monitoring performance and identifying improvement opportunities
• Plan, organize, monitor, oversee, and lead multiple concurrent projects using cross-functional teams
• Lead planning, execution, governance, and delivery of complex Mission Simplify initiatives supporting Provider Data Operations transformation
• Drive initiatives from discovery through implementation and operational transition
• Identify opportunities to increase efficiency, improve service levels, ensure regulatory compliance, and enhance operations
• Develop strategies for improvement opportunities, organizational prioritization, resource alignment, and strategic business objectives
• Manage projects through discovery, requirements gathering, scope definition, planning, resource management, budget oversight, implementation, deployment, and transition
• Develop integrated project plans, milestones, dependencies, RAID logs, and executive status reporting
• Maintain project documentation, including action items, issue logs, risk mitigation plans, business requirements, acceptance criteria, and testing readiness documentation
• Communicate project status through executive summaries, dashboards, presentations, and governance updates
• Negotiate for resources, resolve issues, mitigate risks, and secure stakeholder alignment and formal scope sign-off
• Lead cross-functional meetings and governance routines with Business Analysts, SMEs, technology teams, operational leaders, and business partners
• Provide functional and technical knowledge regarding program requirements, operational processes, and business solution implementation
• Monitor project health and KPIs, identify risks and issues, and develop mitigation plans
• Support change management, training readiness, stakeholder communications, and operational transition activities
• Establish and promote project management standards, tools, templates, and best practices

Program Manager III – Provider Data Operations

Auditor

• Perform internal audits, including strategic, operational, financial, and compliance risk-based audits
• Audit market and shared services Health Plan operations to identify risks, strengthen controls, and drive process improvement
• Execute risk-based audits evaluating controls and processes for scalability, effectiveness, efficiency, and risk mitigation
• Assist with audit planning, refinement of audit work programs, and engagement wrap-up
• Assist in drafting audit reports summarizing findings and recommendations, including metrics consolidation and graphing
• Develop and communicate audit observations, recommendations, process improvement opportunities, and best practices
• Obtain management responses
• Monitor and report audit status and findings
• Assist with special projects and implementation of internal audit best practices
• Perform other assigned duties

Internal Auditor I

• Perform clinical reviews and assess care related to mental health and substance abuse
• Monitor and determine whether levels of care and services are medically appropriate
• Support utilization management and quality improvement efforts
• Identify outlier provider performance
• Conduct comprehensive clinical record reviews
• Deliver individualized coaching to providers
• Synthesize findings into actionable presentations for providers and health plan leadership
• Evaluate member treatment before, during, and after services
• Perform prior authorization reviews according to regulatory guidelines and criteria
• Perform concurrent reviews of behavioral health inpatient care, including treatment needs and discharge planning
• Analyze behavioral health member data to improve quality and appropriate utilization
• Educate providers, members, and families regarding the behavioral health utilization process
• Discuss levels of care and services with behavioral health healthcare providers
• Engage medical directors and leadership to improve care quality and efficiency
• Formulate and present cases in staffing and integrated rounds
• Comply with all policies and standards
• Perform other duties as assigned

Director

• Provide national expertise to support expansion of the business unit’s position nationally regarding the foster care population, treatment and service needs
• Shape evidence-based practices within the foster care provider network, stakeholder system and internal operations
• Participate nationally in evidence-based practice committees, trainings and speaking engagements
• Maintain recognition of national expertise through continued involvement in cutting-edge topics and integration of Cenpatico as a national thought leader
• Provide TF-CBT and other evidence-based training to foster care clinicians nationally
• Maintain involvement with evidence-based practice developers and seek certifications in newly developed clinical methodologies
• Develop learning-collaborative opportunities for foster care clinicians participating in TF-CBT
• Establish consultation opportunities for foster care clinicians
• Lead workgroups to establish a Mental Health Assessment Toolkit for the foster care population, including PTSD, sexual abuse and trauma
• Conduct outreach and develop relationships with potential stakeholders in new and existing markets

Utilization Review Clinician – Behavioral Health

Supervisor, Community Relations Fleet

Manager, IT Portfolio Management

Provider Engagement Account Manager – Southern TX

Utilization Review Clinician – Behavioral Health

Senior Account Relations Manager

Provider Engagement Account Manager – Northeast PA

Account Relations Manager II

Senior IT Assurance Analyst

Provider Engagement Account Manager

Transition Specialist

Program Manager III – Provider Data Operations

Internal Auditor I

Utilization Review Clinician – Behavioral Health

Director, Trauma & Evidence Based Interventions – Foster Care