Centene Corporation

Clinician

• Provide clinical and operational support, guidance, and direction related to utilization management and/or case management
• Develop, implement, and monitor clinical documentation incorporated into clinical guidelines, policies, and procedures
• Draft standardized clinical guidelines aligned with departmental policies and procedures
• Draft new clinical criteria and review and update existing criteria for compliance with state and federal guidelines
• Monitor and organize clinical-focused department SOPs and policies and procedures
• Create new SOPs as needed to facilitate regulatory compliance
• Collaborate with department leadership and Medical Directors on policy and procedure development or modification
• Oversee modification or creation of member and provider letters, determination notices, and other regulatory notices
• Coordinate with internal stakeholders to educate impacted staff on new policies, procedures, and processes
• Measure and evaluate workflow and process effectiveness, identify gaps, and improve performance
• Research industry best practices and published information to support guideline, policy, and procedure development
• Develop and maintain tip sheets, SOPs, audit tools, and other operational documentation
• Obtain data and run basic reports to assess department performance
• Summarize data and create basic presentations to communicate progress to management
• Collaborate with trainers and supervisory staff on implementations and rollout of new policies and procedures
• Review regulatory updates and participate in department projects

Clinician Specialist

Account Manager

• Act as a liaison with vendors and business partners to build 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 and program compliance
• Build reports using performance data to develop metrics and identify vendor process improvements
• Liaise between internal departments and vendors to handle escalations, such as claims
• Represent the company/department in new business and process implementations from launch through day-to-day interactions
• Seek new business opportunities with vendors to create collaborative relationships supporting compliance 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 them and provide product/service updates
• Perform other duties as assigned
• Comply with all policies and standards

Account Relations Manager II

Manager

• Develop, assess, and facilitate complex care management activities for primarily physical-needs members
• Provide personalized care plans and education for members and their families
• Evaluate member needs, barriers to appropriate care, and social determinants of health
• Develop ongoing care plans and collaborate with providers, specialists, and community resources
• Identify care problems and barriers and provide appropriate interventions
• Coordinate between members, families/caregivers, and care provider teams
• Follow up and monitor member status, changes in condition, and progress toward care-plan goals
• Provide resource support for employment, housing, participant direction, independent living, justice, and foster care services
• Facilitate care management and timely access to needed care or services
• Conduct telephonic, digital, home, and other site outreach
• Collect, document, and maintain member information and care-management activities for regulatory compliance
• Educate members and families/caregivers on disease processes, care gaps, provider instructions, care options, referrals, and healthcare benefits
• Provide leadership feedback on opportunities to improve care quality and cost-effectiveness
• Comply with all policies and standards and perform other assigned duties

Care Manager, RN

Learning and Development

• Manage the development, delivery and continuous improvement of training related to the retention aspect of the Medicare line of business
• Facilitate new hire and ongoing training programs
• Leverage needs analysis and evaluation skills to provide curriculum design and development consulting
• Build long-term business relationships with various groups within the organization
• Conduct reviews of learning program objectives and assess the need for modifications to content and structure
• Research current industry trends and recommend and incorporate related updates
• Perform other duties as assigned

Learning Consultant – Retention

Clinical Liaison

• Serve as a liaison for external groups and providers regarding clinical information from Operations and Medical Management teams
• Assess and perform reviews of member clinical records and services related to behavioral health and substance use
• Interpret and present program results
• Develop data-driven analysis and metrics to measure effectiveness and ROI of current and new programs
• Partner with staff and internal and external departments on provider education and outreach
• Identify gaps and develop and deploy education efforts
• Partner with regional leadership on clinical interpretation of health plan reporting, data, and quality incentive payments
• Facilitate discussions and make recommendations
• Implement and manage procedures for tracking, identifying, and resolving operational issues
• Address issues between the provider network, community, and facility, and recommend solutions
• Act as the clinical representative in various meetings
• Collaborate with staff to identify opportunities and initiate process changes to increase quality and improve staff, provider, and member satisfaction
• Serve as a resource and liaison on utilization, quality improvement, and case management activities
• Perform other duties as assigned
• Comply with all policies and standards

Behavioral Health Clinical Liaison

• Serve as a liaison for external groups and providers regarding clinical information from Operations and Medical Management teams
• Assess and review member clinical records and services related to behavioral health and substance use
• Interpret and present program results
• Develop data-driven analysis and metrics to measure program effectiveness and ROI
• Partner with staff and internal/external departments on provider education and outreach
• Identify gaps and develop and deploy education efforts
• Partner with regional leadership regarding clinical interpretation of health plan reporting, data, and quality incentive payments
• Facilitate discussions and make recommendations
• Implement and manage procedures for tracking, identifying, and resolving operational issues
• Act as the clinical representative in meetings
• Collaborate to identify opportunities and initiate process changes to improve quality and staff, provider, and member satisfaction
• Serve as a resource and liaison for utilization, quality improvement, and case management activities
• Perform other duties as assigned
• Comply with all policies and standards

Program Manager

• Drive strategic healthcare transformation initiatives across health plan operations
• Identify opportunities to improve clinical and operational performance, member outcomes and experience, healthcare costs, and regulatory and contractual compliance
• Lead concurrent initiatives from opportunity identification and business case development through implementation and performance measurement
• Partner with clinical operations, Medical Economics, Finance, IT, Product, Provider/Network teams, Payment Integrity, and other cross-functional stakeholders
• Evaluate healthcare quality, clinical and operational efficiency, member outcomes, service levels, regulatory compliance, and medical cost performance
• Lead initiatives across Utilization Management, Care Management, Behavioral Health, LTSS, Clinical Operations, and other payer operations
• Analyze healthcare utilization and cost trends, identify drivers and opportunities, develop business cases, and establish performance measures
• Translate healthcare data and operational findings into strategies, project plans, and measurable interventions
• Develop cost-saving strategies and facilitate prioritization, leadership alignment, and resource allocation
• Manage projects through discovery, requirements gathering, planning, implementation, measurement, and transition to operational ownership
• Establish objectives, milestones, deliverables, dependencies, risks, decision points, performance measures, governance, and documentation
• Lead cross-functional workgroups and drive decisions and defined outcomes
• Translate business and clinical requirements into technology-enabled solutions and ensure implementation and adoption
• Monitor post-implementation performance, validate realized impact, and identify continued improvement opportunities
• Communicate project status, risks, financial opportunities, decisions, and performance to senior and executive leadership
• Negotiate with stakeholders to secure resources, resolve issues, mitigate risks, and maintain progress
• Maintain knowledge of managed care operations, healthcare trends, regulatory requirements, and Medicaid considerations

Program Manager III

Nurse

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

Clinical Review Nurse – Concurrent Review

Authorization Specialist

• Act as a resource and support the prior authorization request process
• Ensure authorization requests are addressed properly within contractual timelines
• Support the utilization management team with documentation and tracking of authorization requests and referrals
• Research and document medical information for referral to clinical reviewers
• Verify member insurance coverage and service/benefit eligibility
• Align authorizations with guidelines to support timely payment adjudication
• Enter and update authorization requests in the utilization management system
• Process authorization requests according to the insurance prior authorization list
• Route requests to the appropriate clinical reviewer
• Remain up-to-date on healthcare, authorization processes, policies, and procedures
• Comply with all policies and standards
• Perform other duties as assigned

Authorization Specialist II

Operations

• Provide direct supervision to entry and/or processing staff
• Hire, train, evaluate, develop and manage staff performance
• Monitor and direct workflow to ensure timely and accurate processing
• Develop policies and procedures to improve efficiencies and support new contracts or programs
• Interface with internal staff, field personnel, other contractors and customers
• Create and monitor reports for process control and production effectiveness
• Make adjustments to maintain quality standards and achieve operational goals
• Monitor production and quality effectiveness, assign resources and recommend process improvements
• Respond to customer inquiries and track issues
• Represent the department to promote relationships, improve processes and secure goals
• Collect and analyze operational data to identify efficiency improvements
• Perform quality control and provide staff feedback and coaching
• Handle administrative issues, disciplinary matters, timekeeping and scheduling
• Handle escalations
• Work on special projects
• Construct procedures for new programs or contracts with department staff
• Develop relationships with other departments to support collaboration and customer satisfaction
• Comply with policies and standards and perform other duties as assigned

Operations Supervisor

Analyst

• Monitor and investigate broker data for compliance
• Drive remediation of variances
• Generate responses for multiple audits
• Create, analyze, and monitor broker compliance data for the Marketplace Broker Oversight team
• Manage broker audits, conduct audits, and monitor brokers for next action
• Create dashboards, Smartsheet, and reports to monitor broker compliance
• Communicate with brokers regarding requests for audit information and follow up
• Direct, monitor, and/or contribute to highly complex special projects and planning initiatives involving complaint oversight
• Deliver education to brokers regarding audit findings

Brokerage Auditing Analyst – Healthcare

• Develop, assess, and facilitate complex care management activities for members with primarily physical needs
• Evaluate member needs, barriers to care, and social determinants of health
• Develop ongoing care plans and collaborate with providers, specialists, and community resources
• Identify problems and barriers to care and provide appropriate interventions
• Coordinate person-centered care among members, families, caregivers, and provider teams
• Follow up and monitor member status, conditions, and progress toward care plan goals
• Provide resource support for services including employment, housing, independent living, justice, and foster care
• Facilitate timely access to needed care and services
• Conduct telephonic, digital, home, and other site outreach
• Collect, document, and maintain member information and care management activities for regulatory compliance
• Educate members and families/caregivers on disease processes, care gaps, provider instructions, care options, referrals, and healthcare benefits
• Provide leadership feedback on opportunities to improve care quality and cost-effectiveness
• Perform other duties as assigned

• Performs concurrent reviews to determine members’ overall health, appropriate care, and level of care
• Reviews quality and continuity of care, including acuity level, resource consumption, length of stay, and discharge planning
• Works with Medical Affairs and/or Medical Directors to discuss member care
• Collects, documents, and maintains concurrent review findings, discharge plans, and actions in health management systems
• Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and review findings
• Educates providers on utilization processes to support high-quality, appropriate care
• Provides leadership feedback on opportunities to improve level of care and medical necessity
• Reviews transfer and discharge plans to support timely transitions between care levels and facilities
• Collaborates with care management on member referrals
• Performs other assigned duties

• Promote increased program efficiency, service levels, and value by capturing and monitoring performance
• Identify opportunities for improvement and strategies to realize those opportunities
• Plan, organize, monitor, oversee and lead multiple concurrent projects using cross-functional teams
• Ensure projects deliver defined requirements and meet company strategic objectives
• Identify opportunities to increase efficiency, improve service levels, and ensure regulatory compliance through enhanced operations
• Develop strategies for improvement opportunities and ensure organizational prioritization and resource alignment
• Manage multiple projects through the full project life cycle, including requirements gathering, project plans and schedules, resource management, budgeting, execution, deployment and closure
• Utilize corporate and industry-standard project management tools and techniques
• Maintain project documentation, including 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 to meet stakeholder expectations and company objectives
• Provide functional and technical knowledge regarding overall program requirements and operations