Centene Corporation

Nurse

• Perform concurrent reviews to determine members’ overall health, appropriate care, and level of care
• Review acuity, resource consumption, length of stay, quality and continuity of care, and discharge planning
• Evaluate inpatient services to validate medical necessity and care setting
• Work with Medical Affairs and/or Medical Directors regarding 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 and discharge plans to support timely transitions between care levels and facilities
• Collaborate with care management on member referrals
• Perform other assigned duties and comply with policies and standards

Clinical Review Nurse – Concurrent Review

Assessor

• Perform care management duties for complex/high-acuity populations with primary medical/physical health needs
• Conduct UAS Assessments for the MLTC member population with Fidelis
• Evaluate service needs and recommend plans for optimal outcomes
• Develop and continuously assess long-term care and service plans
• Collaborate with care management teams to identify providers, specialists, and community resources
• Coordinate with members, families/caregivers, and care provider teams to ensure person-centered care
• Monitor member status, complications, symptoms, care-plan progress, and changes in condition
• Review member data, referrals, and intake assessments to improve care quality and operating performance
• Collaborate with healthcare providers to facilitate services and treatments and revise care plans
• Collect, document, and maintain member information and care management activities
• Educate members and families/caregivers on disease processes, care gaps, provider instructions, care options, referrals, and healthcare benefits
• Act as liaison and advocate among members, families, physicians, facilities, and agencies
• Coordinate community resources and service authorizations for services such as meals, employment, housing, foster care, transportation, and activities of daily living
• Perform home and/or other site visits as required
• 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 duties as assigned and comply with all policies and standards

Senior UAS LTSS Assessor, RN

Supervisor

• Supervise behavioral health utilization review clinicians and day-to-day utilization management team activities
• Monitor clinicians for compliance with applicable guidelines
• Track BH utilization management resources against performance, quality, and efficiency standards
• Resolve complex behavioral health member care issues
• Maintain knowledge of regulations, accreditation standards, and industry best practices
• Identify process and quality improvement opportunities with the team and senior management
• Educate the team and provide resources on key initiatives
• Develop and implement utilization management policies, procedures, and guidelines
• Evaluate team performance and provide feedback on goals and career milestones
• Coach and guide team members; provide counseling and corrective action when required
• Assist with onboarding, hiring, and training team members
• Attend company meetings in the people leader's absence
• Serve as primary contact for escalated calls and issues requiring research or special handling
• Lead and manage others in a matrixed/cross-functional environment
• Champion change within the scope of responsibility
• Present information and respond to questions from peers, leaders, and internal/external customers
• Perform other assigned duties and comply with all policies and standards

Supervisor, Behavioral Health Utilization Management

• 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 regarding member care
• Collect, document, and maintain concurrent 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 and discharge plans to ensure 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

Data Analyst

• Handle complex data requests, reports, and predictive data modeling
• Analyze health management programs, including data collection, validation, and outcome measurement
• Analyze financial, pharmacy, claims, provider, and member data
• Perform IRS, CMS, HHSC, 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 Business Objects interface and direct links to ODS/EDW databases
• 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
• Assist with training lower-level Data Analysts
• Perform other duties as assigned
• Comply with all policies and standards

Data Analyst II

• Lead clinical coding compliance nurses and non-clinical team members through the code editing adjudication process
• Oversee prepay compliance, adjustments, and appeals for multiple code editing software systems
• Ensure the Coding Analytics team meets production standards and passes quality audits
• Oversee relationships with health plans, Claims, and other departments
• Identify and implement best practices and operational efficiencies
• Serve as a health plan account liaison and provide expertise on code editing decisions
• Research coding questions and issues
• Provide expert testimony in state fair hearings and to health plan leadership regarding state complaints from providers
• Triage and resolve escalated health plan, Claims department, and provider inquiries or issues
• Coordinate communication across IT, health plans, vendors, and affected departments
• Perform other duties as assigned

Supervisor, Payment Integrity – Appeals & Disputes

Financial Planning and Analysis

• Partner with internal and external stakeholders to support Centene's Provider Network team and company goals through cost-saving initiatives
• Serve as a key stakeholder across multiple markets and lines of business
• Compile and analyze financial information
• Lead complex financial projects
• Provide data-driven insights for network and reimbursement-related business decisions
• Identify trends and developments in competitive environments and present findings to senior management
• Lead market calls and support day-to-day market needs
• Develop integrated revenue/expense analyses, projections, reports, and presentations
• Perform financial forecasting and reconciliation of internal accounts
• Handle complex and high-level financial analysis
• Present and discuss analysis with upper management
• Create and analyze monthly, quarterly, and annual reports and ensure financial information is recorded accurately
• Manage multiple high-value initiatives from planning through implementation and completion
• Work with project management and leadership to ensure initiatives remain on track and goals/timelines are met

Finance Analyst III, Managed Care

• Perform care management duties for complex/high-acuity populations with primary medical/physical health needs
• Conduct UAS assessments for MLTC members with Fidelis
• Evaluate service needs and recommend plans for optimal outcomes
• Develop and continuously assess long-term care and service plans
• Coordinate members, families/caregivers, providers, specialists, and community resources
• Monitor member status, care-plan progress, complications, clinical symptoms, and changes in condition
• Identify needs for higher levels of care and waiver eligibility
• Review member data, referrals, and intake assessments to improve quality and operating performance
• Facilitate member services, treatments, service authorizations, and revised care plans
• Collect, document, and maintain member and care-management information
• Educate members and caregivers on disease processes, care gaps, provider instructions, care options, referrals, benefits, and community resources
• Act as liaison and advocate between members/families, physicians, facilities, and agencies
• Conduct 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 during onboarding and field practice
• Perform other assigned duties and comply with policies and standards

• Oversee preparation of accurate and timely financial reports related to key revenue drivers such as membership volume
• Oversee financial and business analyses based on sales, marketing, provider network and regulatory change information
• Assess and model market penetration based on sales, marketing and provider network metrics
• Develop scenario planning and event-driven analysis for membership volume impact related to management decisions around market entry/exit
• Develop multi-year membership and revenue projection models and scenario planning
• Prepare budgets and forecasts and analyze financial results across dimensions such as geography and sales channel for membership and revenue
• Manage month-end, quarter-end and year-end closing processes and support analytical packages for periodic business reviews
• Develop and manage financial/data analysts to improve timely and accurate reporting of multidimensional revenue and membership data

Senior Manager, Finance FP&A

Manager

• Develop, assess, and facilitate complex care management activities for primarily mental and behavioral health needs
• Evaluate member needs via phone or in-home visits and recommend or facilitate care/service plans
• Conduct telephonic, digital, home, and/or other site-visit outreach
• Develop ongoing care plans for high-acuity members and identify providers, specialists, and community resources
• Coordinate among members, families/caregivers, community resources, and care provider teams
• Monitor care plans, member status, treatment side effects, complications, and clinical symptoms
• Facilitate care coordination with providers and specialists for timely access to care
• Collect, document, and maintain member information and care management activities for regulatory compliance
• Educate members and families about procedures, provider instructions, treatment 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 – Foster Care

• Perform care management duties to 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
• Conduct UAS Assessments for the MLTC member population with Fidelis
• Evaluate complex or high-risk/high-acuity members' service needs and recommend care plans
• Collaborate with care management teams to identify providers, specialists, and community resources
• Coordinate between members/families/caregivers and care provider teams to ensure appropriate person-centered care
• Monitor care plans, member status, changes in condition, complications, symptoms, and progress toward goals
• Review member data, referrals, and intake assessments to improve care quality and operating performance
• Collaborate with healthcare providers to facilitate services and treatments and revise care plans
• Collect, document, and maintain member information and care management activities
• 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 among members/families, physicians, facilities, and agencies
• Coordinate service authorizations for services such as meals, employment, housing, foster care, transportation, and activities of daily living
• May conduct home and other site visits, such as monthly or more often, to assess member needs and collaborate with resources
• Partner with leadership to improve quality of care and cost-effective service delivery
• May precept clinical new hires and provide coaching, shadowing, onboarding, and competency support
• Engage with People Leaders and cross-functional teams to monitor new-hire readiness
• Perform other assigned duties and comply with policies and standards

Senior LTSS Service Care Manager, RN

• Develop, assess, and facilitate complex care management activities for primarily mental and behavioral health needs
• Provide high-quality, cost-effective healthcare outcomes, personalized care plans, and education for members and families
• Evaluate member needs via phone or in-home visits and recommend or facilitate care/service plans
• Conduct telephonic, digital, home, and/or other site-visit outreach
• Develop ongoing care plans for members with high acuity
• Identify providers, specialists, and community resources for mental health and substance use disorders
• Coordinate among members, families/caregivers, community resources, and care provider teams
• Monitor care plans, member status, treatment side effects, complications, and clinical symptoms
• Facilitate care coordination and timely access to needed care or services
• Collect, document, and maintain member information and care management activities for regulatory compliance
• Educate members and families on procedures, provider instructions, treatment options, referrals, and healthcare benefits
• Provide leadership feedback on opportunities to improve care quality and cost-effectiveness
• Comply with all policies and standards
• Perform other duties as assigned

Care Manager – BH, Foster Care

Care Coordinator

• Support care management activities and assigned member teams
• Ensure services are delivered by healthcare providers and partners
• Perform member outreach by telephone and home visits
• Document care/service plans, activities, member needs, and records
• Discuss next steps, resources, questions, concerns, recommended care, and ongoing education with members
• Coordinate care activities with healthcare providers, community providers, partners, members, and caregivers
• Respond to member and provider inquiries, requests, and concerns
• Communicate with care managers, practitioners, and others to facilitate services and continuity of care
• Support service assessments and screenings
• Identify needs and make referrals to Care Managers, community-based organizations, and Disease Managers
• Provide education on available benefits and resources
• Follow standards of practice and comply with contractual, regulatory, and organizational requirements
• Perform other duties as assigned

Care Coordinator II

Patient Care

• Work with members and providers to close care gaps and remove barriers to care
• Improve member and provider experience through outreach and face-to-face interaction
• Collaborate with providers in the field to improve HEDIS measures
• Educate providers on HEDIS measures and coding
• Support quality improvement interventions and provider audits
• Assist in resolving deficiencies affecting compliance with State and Federal HEDIS standards
• Conduct telephonic outreach and health coaching to members identified as needing preventive services
• Provide face-to-face education to members and families about care gaps and barriers to care
• Schedule doctor appointments and arrange transportation and follow-up appointments
• Connect members with community-based resources and affinity programs
• Act as liaison and member advocate between members/families, physicians, facilities, and agencies
• Serve as WellCare's representative in provider offices
• Advise provider practices on HEDIS ICD-10/CPT coding under NCQA requirements
• Assess provider performance data and strategize provider improvement opportunities
• Collaborate with Provider Relations on Quality, Risk Adjustment, Operations, claims, and encounters
• Document all member-contact actions
• Interact with departments including customer service to resolve member issues
• Refer members to case or disease management as appropriate
• Complete special assignments and projects
• Perform other duties as assigned and comply with policies and standards

Patient Care Advocate

Director

• Lead and direct process improvement activities to create more efficient and streamlined workflows
• Shape and execute the organization's digital quality measurement strategy
• Lead and collaborate on NCQA Accreditation and/or HEDIS performance
• Lead quality improvement aspects of risk adjustment processes for all products
• Collaborate with the Medicare STARS team to improve STARS ratings, including HEDIS, CAHPS, and HOS
• Oversee provider satisfaction surveys and implement improvement action plans
• Research and incorporate best practices into operations
• Organize and control activities, methods, and procedures to achieve business objectives
• Review and implement new technological tools and processes
• Foster team concepts with internal and external constituencies
• Present improvement results and ongoing performance measures to senior management
• Formulate and establish policies, operating procedures, and goals in compliance with internal and external guidelines
• Lead the strategy, roadmap, testing, validation, and audit readiness for digital quality measurement, HEDIS, and related clinical quality initiatives

Clinical Review Nurse – Concurrent Review

Senior UAS LTSS Assessor, RN

Supervisor, Behavioral Health Utilization Management

Clinical Review Nurse – Concurrent Review

Data Analyst II

Supervisor, Payment Integrity – Appeals & Disputes

Finance Analyst III, Managed Care

Senior UAS LTSS Assessor, RN

Senior Manager, Finance FP&A

Care Manager – Foster Care

Senior LTSS Service Care Manager, RN

Care Manager – BH, Foster Care

Care Coordinator II

Patient Care Advocate

Director, Quality Improvement – Digital Quality Measurement