Centene Corporation

General

• Coordinate and negotiate hospital, physician, IPA, PPM, individual provider, multi-specialty group, and ancillary service agreements
• Negotiate SCA rates within parameters and escalate issues as they arise
• Create SCAs using approved language and rates
• Route and follow SCAs through the SharePoint system
• Notify internal and external customers upon SCA execution and post SCAs in assigned folders
• Assist teams with participating provider options and supply appropriate choices
• Redirect requests to cost-effective alternative providers when participating providers are unavailable
• Notify management about providers willing to contract for gaps or access-to-care concerns
• Prioritize urgent requests, imminent discharges/transfers, and complaints
• Provide timely redirection options to avoid unnecessary SCAs

Contract Negotiator, III

Investigator

• Conduct comprehensive reviews of medical records and documents supporting claims for providers, suppliers, pharmacies, and various healthcare services
• Provide investigative support to the Special Investigations Unit related to coding and billing issues
• Identify potential overpayments and suspected healthcare fraud and abuse
• Verify service authorizations and written documentation against claim information
• Ensure diagnosis and procedure codes supporting claims are appropriate and accurate
• Coordinate medical necessity and level-of-care determinations with Medical Directors
• Validate services against CMS and state-specific coverage, limitation, and exclusion guidelines
• Coordinate with internal and external resources to determine code appropriateness in administrative, medical, claim, and financial records
• Develop reports of findings and recommendations
• Communicate complex audit findings in meetings and/or judicial hearings
• Assist SIU investigators during interviews, discussions, and negotiations with providers, suppliers, and pharmacies
• Perform retrospective and prepayment medical-record reviews to identify fraud, waste, abuse, and inappropriate billing practices
• Investigate and analyze provider billing patterns to determine payment based on records, claims, codes, regulations, guidelines, and policies
• Prepare summaries of findings and recommend next steps for providers
• Identify preventive measures and recommend policy, procedure, and/or provider-practice changes
• Collaborate with investigators to identify abuse and fraud using clinical and coding expertise
• Perform other duties as assigned
• Comply with all policies and standards

Clinical Investigator, Behavioral Health

Quality Specialist

• Assist with daily operations and support within the Quality Improvement department
• Manage the HEDIS project, including nurse assignments, plan timeline adherence, and vendor oversight for timeliness and quality
• Assist with data collection, data entry, and report generation for QI initiatives
• Support access and availability studies, HEDIS abstraction forms, medical records/site reviews, and member and physician satisfaction studies
• Analyze data and write reports for committee discussion
• Research and write provider newsletters and educational materials
• Conduct interdepartmental inter-rater reliability audits
• Design, run, and manage data review processes to ensure report accuracy and integrity
• Implement process improvements to streamline departmental functions
• Assist the Director, QI with regulatory agency and review organization audits
• Perform other assigned duties
• Comply with all policies and standards

Quality Improvement Specialist II

• Work with the Marketing & Community Relations Manager to develop and implement the Health Plan’s community outreach plan
• Participate in developing and implementing Marketing team strategies
• Contribute to member growth goals
• Maintain knowledge of healthcare programs and regulatory marketing guidelines
• Identify and develop relationships with community contacts and organizations
• Develop and implement promotional plans for outreach opportunities
• Coordinate outreach activities, materials, community events and health events
• Attend events to distribute Health Plan information
• Support scheduling and delivery of health education presentations
• Organize Health Plan staff and resources for community events and activities
• Distribute written materials to customers who request them
• Support Health Plan-sponsored school programs
• Perform other duties as assigned
• Comply with policies and standards

Community Relations Coordinator

Account Manager

• Develop strategic partnerships between the health plan and contracted provider networks
• Engage providers to align on network performance opportunities and solutions
• Provide consultative account management and accountability for issue resolution
• Drive performance in contract incentive performance, quality, and cost utilization
• Participate in development of network management strategies
• Implement initiatives for performance improvement
• Serve as primary contact and liaison between providers and the health plan
• Identify and deliver solutions to provider concerns and issues
• Respond to external provider-related issues
• Investigate, resolve, and communicate provider claim issues and changes
• Educate providers on referrals, claims submission, website usage, EDI solicitation, and related topics
• Perform provider orientations and ongoing education; write and update orientation materials
• Manage network performance for assigned territory through consultative account management
• Evaluate provider performance and develop strategic improvement plans
• Drive improvement in Risk/P4Q, HBR, HEDIS/quality, cost, and utilization
• Present HBR analysis and create reports for Joint Operating Committee meetings
• Develop proficiency in VBP tools and educate providers on tool use and data interpretation
• Coach new and less experienced External Representatives
• Perform other assigned duties and comply with policies and standards

Senior Provider Engagement Account Manager

Business Analyst

• Support business initiatives through data analysis, identification of implementation barriers, and user acceptance testing of various systems
• Identify and analyze user requirements, procedures, and problems to improve existing processes
• Perform detailed analysis on multiple projects, recommend potential business solutions, and ensure successful implementations
• Identify ways to enhance performance management and operational reports related to new business implementation processes
• Coordinate with various business units and departments in the development and delivery of training programs
• Develop, share, and incorporate organizational best practices into business applications
• Diagnose problems and identify opportunities for process redesign and improvement
• Formulate and update departmental policies and procedures
• Serve as the subject matter expert on the assigned function product to ensure operational performance
• Perform other duties as assigned
• Comply with all policies and standards

Business Analyst III – Pharmacy Enrollment Operations

Call Center Representative

• Support review and analysis of contact center operational processes
• Provide data-driven insights related to operational targets, best practices, and training programs
• Gather, analyze, and interpret contact center data and operational processes for leadership reports
• Identify operational improvement opportunities and recommendations for remediation
• Prepare financial and quality impact analyses and final reports
• Perform preliminary analysis of testing results and identify potential causes of failure
• Track operational processes, develop dashboards, and evaluate improvement opportunities
• Notify contact center employees about process improvement opportunities and provide short-term resolutions
• Develop and maintain dashboards to assess operational performance and identify trends
• Document best practices, policies, and standards in desktop procedures
• Support ongoing training programs for service, quality, efficiency, and productivity
• Perform other duties as assigned

Contact Center Operations Analyst I

• Support business initiatives through data analysis, identification of implementation barriers, and user acceptance testing of new systems
• Identify and analyze user requirements, procedures, and problems to improve existing processes
• Perform detailed analysis on assigned projects, recommend potential business solutions, and assist with implementation
• Identify ways to enhance performance management and operational reports related to new business implementation processes
• Develop and incorporate organizational best practices into business applications
• Assist with formulating and updating departmental policies and procedures
• Perform other duties as assigned
• Comply with all policies and standards

Business Analyst II – Contact Center Operations

Director

• Oversee claims configuration and pricing/benefits setup within the claims payment system
• Ensure accurate reflection of provider contracts and claims payments
• Ensure timely and accurate configurations and pricing/benefits setup for new business implementations
• Ensure changes in provider contracts are reflected in the claims payment system
• Collaborate with stakeholders to gather business requirements for system configurations and setup
• Identify and implement opportunities to automate processes
• Oversee evaluation and analysis of upcoming implementations
• Ensure successful and smooth transition into claims systems and processes

Director, Claims Configuration

Care Coordinator

• Support care management activities and assigned care teams
• Perform member outreach by telephone or home visits
• Discuss care plans, service plans, next steps, resources, questions, and concerns with members
• Coordinate care activities with healthcare and community providers, partners, members, and caregivers
• Support member and provider inquiries and concerns related to care plans and service plans
• Communicate with care managers, practitioners, and others to facilitate member services and continuity of care
• Support service assessments and screenings and document member care needs
• Maintain member records according to state and regulatory requirements
• Follow contractual, regulatory, and organizational standards and policies
• Identify needs and make referrals to Care Managers, community-based organizations, and Disease Managers
• Provide education about available benefits and resources
• Perform other duties as assigned

Care Coordinator II

• Develop strategic partnerships between the health plan and contracted provider networks
• Engage providers to align on network performance opportunities and solutions
• Manage provider accounts and ensure accountability for issue resolution
• Drive performance in contract incentive performance, quality, and cost utilization
• Participate in developing network management strategies
• Implement initiatives for performance improvement
• Serve as primary provider contact and liaison with the health plan
• Identify and deliver solutions to provider concerns and issues
• Respond to external provider-related issues
• Investigate, resolve, and communicate provider claim issues and changes
• Educate providers on referrals, claims submission, website usage, EDI solicitation, and related topics
• Perform provider orientations and ongoing provider education
• Manage network performance for assigned territory through consultative account management
• Evaluate provider performance and develop strategic improvement plans
• Drive improvement in Risk/P4Q, HBR, HEDIS/quality, cost, and utilization
• Present HBR analysis and create reports for Joint Operating Committee meetings
• Develop proficiency in value-based performance tools and educate providers on data interpretation
• Coach new and less experienced External Representatives
• Perform other assigned duties and comply with policies and standards

Nurse

• Perform concurrent reviews to determine members’ overall health, appropriate care, medical necessity, and level of care
• Review acuity level, resource consumption, length of stay, and discharge planning
• Work with Medical Affairs and/or Medical Directors regarding member care
• Document concurrent review findings, discharge plans, and actions in medical records and health management systems
• Work with healthcare providers on medical determinations and recommendations
• Educate providers on utilization processes
• Provide leadership feedback on appropriate level of care and medical necessity improvements
• Review transfer and discharge plans to support timely transitions between care levels and facilities
• Collaborate with care management on member referrals
• Comply with policies and standards and perform other assigned duties

Clinical Review Nurse – Concurrent Review

Data Analyst

• Analyze integrated and extensive datasets to extract value that impacts and influences business decisions
• Collaborate with key business stakeholders to identify areas of value, develop solutions, and deliver insights to reduce overall cost of care and improve clinical outcomes
• Interpret and analyze data from healthcare provider, member/patient, and third-party sources
• Support execution of large-scale projects with limited direction from leadership
• Identify and perform root-cause analysis of data irregularities and present findings and proposed solutions to leadership and/or customers
• Manage multiple, variable tasks and data review processes within targeted timelines
• Support the design, testing, and implementation of process enhancements and identify opportunities for automation
• Apply quantitative analysis, data mining, and data presentation expertise to understand customer interactions with analytic products
• Communicate findings and insights to non-technical business partners verbally and visually
• Engage independently with customers and business partners to gather requirements and validate results
• Present data-driven insights and recommendations to internal and external stakeholders and incorporate feedback
• Perform other duties as assigned
• Comply with all policies and standards

Data Analyst II – Healthcare Analytics

Data Engineer

• Develop and operationalize data pipelines for reports and advanced analytics
• Design, develop, maintain, and optimize Snowflake and AWS data pipelines, reporting solutions, and data products
• Build scalable ingestion, transformation, validation, and publishing processes
• Translate business requirements into technical designs, user stories, process flows, and scalable solutions
• Develop and maintain technical documentation, solution designs, operational runbooks, and supporting artifacts
• Integrate data across Member, Provider, Claims/Encounter, Quality, and Financial domains
• Implement data quality, monitoring, validation, reconciliation, automated testing, and exception-management frameworks
• Support cloud modernization and migration of legacy platforms to Snowflake and AWS
• Troubleshoot production issues, perform root-cause analysis, and implement sustainable solutions
• Establish engineering best practices across source control, CI/CD, automation, testing, documentation, and cloud architecture
• Collaborate within Agile delivery teams through planning, estimation, testing, deployment, and continuous improvement
• Partner with business and technology stakeholders to improve operational efficiency and deliver high-quality data solutions

Senior Data Engineer

Attorney

• Independently manage complex document preparation and processing
• Coordinate and track multiple case files and legal matters simultaneously
• Prepare and file legal documents with courts and government agencies
• Review documents for completeness and compliance with filing requirements
• Serve as a resource for junior support staff on procedures and processes
• Manage vendor relationships for legal services, including court reporters and process servers
• Coordinate logistics for trials, hearings, and depositions
• Reconcile billing and expense reports for legal matters
• Develop and maintain templates and standard operating procedures
• Handle sensitive and confidential information with discretion
• Perform other duties as assigned
• Comply with all policies and standards

Contract Negotiator, III

Clinical Investigator, Behavioral Health

Quality Improvement Specialist II

Community Relations Coordinator

Senior Provider Engagement Account Manager

Business Analyst III – Pharmacy Enrollment Operations

Contact Center Operations Analyst I

Business Analyst II – Contact Center Operations

Director, Claims Configuration

Care Coordinator II

Senior Provider Engagement Account Manager

Clinical Review Nurse – Concurrent Review

Data Analyst II – Healthcare Analytics

Senior Data Engineer

Legal Support Generalist III