Centene Corporation

Program Manager

• Lead cross-functional COB, TPL, and Subrogation initiatives, including vendor implementations, operational enhancements, regulatory readiness efforts, and recovery optimization projects
• Coordinate initiatives across multiple health plans and lines of business
• Organize work across operational teams and facilitate meetings with internal stakeholders and external vendors
• Track deliverables, manage issue resolution, and ensure timely execution of strategic priorities
• Support business department initiatives promoting quality, safety, and cost-of-care opportunities
• Gather requirements, create plans and schedules, manage resources, and facilitate project execution and deployment
• Maintain business process documentation, including meeting minutes, action items, issue lists, and risk management plans
• Create and monitor department deliverables, including clinical reporting documents, reference materials, and policy and procedure documentation
• Communicate program status to management and key stakeholders
• Identify resources, resolve issues, and mitigate risks
• Improve existing processes by identifying requirements, procedures, and problems
• Coordinate cross-functional meetings to meet stakeholder expectations and business objectives
• Manage projects through the full project life cycle
• Provide leadership and communicate project status to stakeholders
• Negotiate with stakeholders to secure resources, resolve issues, and mitigate risks
• Perform other duties as assigned and comply with policies and standards

Program Manager II – COB, TPL, Subrogation

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

Director, Quality Improvement – Digital Quality Measurement

Manager

• Develop, assess, and facilitate complex care management activities for members with primarily physical needs
• Create personalized care plans and provide education for members and families
• Evaluate member needs, access barriers, and social determinants of health
• Develop ongoing care/service plans and collaborate with providers, specialists, and community resources
• Identify problems and barriers to care and provide care management interventions
• Coordinate members, families/caregivers, and care provider teams to ensure appropriate person-centered care
• Follow up and monitor member status, condition changes, and progress toward care plan goals
• Provide resource support for employment, housing, participant direction, independent living, justice, and foster care services
• 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 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-effective delivery
• Perform other duties as assigned and comply with all policies and standards

Care Manager, RN

• Plan, organize, monitor, and oversee programs using cross-functional teams to deliver defined requirements and meet business needs and strategic objectives
• Serve as the primary coordinator for Recovery Operations and Recovery Platform initiatives
• Organize work across operational, business, and technology teams
• Facilitate meetings with internal stakeholders and external partners
• Manage issue resolution and ensure timely delivery of strategic priorities
• Monitor recovery inventory, operational performance, and platform-related initiatives
• Identify risks and bottlenecks and coordinate remediation efforts with BTS and business teams
• Provide executive-level reporting on program status, issues, and key performance metrics
• Support business department initiatives that promote quality, safety, and cost-of-care opportunities
• Gather requirements, create plans and schedules, manage resources, and facilitate project execution and deployment
• Use corporate and industry-standard tools and techniques to oversee programs
• Maintain business process documentation, including meeting minutes, action items, issue lists, and risk management plans
• Create and monitor department deliverables to ensure adherence to quality standards
• Communicate program status to management and key stakeholders
• Identify resources, resolve issues, and mitigate risks
• Identify requirements, procedures, and problems to improve existing processes
• Coordinate cross-functional meetings to meet stakeholder expectations and business objectives
• Manage projects through the full project life cycle
• Provide leadership and communicate project status to stakeholders
• Negotiate with stakeholders to secure resources, resolve issues, and mitigate risks
• Perform other duties as assigned
• Comply with all policies and standards

Program Manager II – Recovery Operations

Data Management

• Manage the daily operations of provider data management functions
• Direct provider data management activities based on plan and contract specifications and standard business rules
• Manage end-to-end provider data entry and maintenance for claims payment, member assignment and directory display
• Investigate and resolve complex provider data management issues
• Identify trends and recommend improvements to mitigate potential issues
• Lead task assignment for team workflow and distribution
• Monitor team performance against provider data quality benchmarks
• Facilitate meetings with Health Plan representatives
• Train and mentor Provider Data Management Analysts I and II and Team Leads
• Perform other duties as assigned
• Comply with all policies and standards

Supervisor, Provider Data Management

• Perform care management duties for complex/high-acuity populations with primary medical/physical health needs
• Assess and coordinate medical and supporting services across the continuum of care
• Develop personalized care plans/service plans for long-term care members
• Evaluate complex or high-risk members' service needs and recommend outcome-focused plans
• Continuously assess care plans and collaborate with care management teams to identify providers, specialists, and community resources
• Coordinate between members/families/caregivers and care provider teams to ensure person-centered care
• Monitor care plans, member status, changes in condition, complications, clinical symptoms, and progress toward goals
• Review member data, referrals, and intake assessments to improve 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 benefits
• Act as liaison and member advocate between members/families, physicians, and facilities/agencies
• Coordinate community resources and service authorizations, including meals, employment, housing, foster care, transportation, and activities of daily living
• Perform home and other site visits, potentially once a month or more, to assess needs and collaborate with resources
• Partner with leadership to improve quality and cost-effective service delivery
• May precept and coach clinical new hires, support onboarding, complete competency checkpoints, and monitor readiness
• Perform other assigned duties and comply with policies and standards

Senior LTSS Service Care Manager, RN

Strategy

• Oversee administrative functions and strategic initiatives
• Assist executive leadership with strategic planning, competitive intelligence, strategic advocacy, and chief of staff responsibilities
• Lead end-to-end process transformation initiatives across Claims, Appeals & Grievances, Enrollment, Provider Data, Billing, and related operational domains
• Support future-state operating models that improve scalability, quality, compliance, and operational effectiveness through process design and support
• Partner with Operations, Technology, Compliance, Analytics, and Business stakeholders to implement sustainable process improvements
• Reduce unnecessary variation, eliminate duplicate work, and standardize business processes across lines of business and cross-functional teams
• Coordinate, deliver, and maintain the annual enterprise-level strategic plan
• Partner with executive leadership to identify and monitor strategic priorities
• Partner with HR to lead and manage the annual people plan, including career development, training, and education strategies
• Lead the development and oversight of the competitive intelligence process
• Develop and mature strategic, innovative partnerships to drive advocacy for the Division's lines of business
• Deliver and support chief of staff responsibilities, including presentation development, governance management, communications, and priority projects
• Perform other duties as assigned
• Comply with all policies and standards

Vice President – Strategic Initiatives

• 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
• Lead the end-to-end SSBCI program across business operations, data, technology, vendors, compliance, customer service, enrollment, and member experience
• Create structure, manage dependencies, clarify requirements, owners, dates, decisions, and next steps
• Identify gaps and risks, separate immediate safeguards from long-term solutions, drive issues to closure, and provide updates on progress, risks, decisions, and member impact
• Identify opportunities to increase efficiency, improve service levels, and ensure regulatory compliance through enhanced operations
• Develop improvement strategies and ensure organizational prioritization and resource alignment
• Manage projects through the full project life cycle, including requirements gathering, project planning, scheduling, resource management, budgeting, execution, deployment, and closure
• Use corporate and industry-standard project management tools and techniques
• Maintain project documentation, action items, issue lists, and risk mitigation plans
• 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 program requirements and operations

Program Manager III – SSBCI

Care Coordinator

• Develop, assess, and coordinate holistic care management activities for long-term care members
• Develop or assist with personalized service care plans/service plans
• Educate members and families/caregivers on available services, benefits, procedures, provider instructions, service options, referrals, and healthcare benefits
• Evaluate member needs and available resources and recommend or facilitate the best outcome
• Develop ongoing long-term care plans and identify providers, specialists, and community resources
• Coordinate between members/families/caregivers and care provider teams to ensure services are accessible
• Provide resource support for employment, housing, participant direction, independent living, justice, and foster care needs
• Monitor care plans, member status, and outcomes and recommend updates based on member needs
• Interact with long-term care providers and partners to meet member needs
• Collect, document, and maintain member information and care management activities for regulatory compliance
• Perform on-site visits as needed to assess member needs and collaborate with providers/resources
• Provide feedback to leadership on improving quality of care and cost-effective service delivery
• Perform other duties as assigned

LTSS Service Care Coordinator

• Develop, assess, and coordinate holistic care management activities for quality, cost-effective healthcare outcomes
• Develop or assist with personalized service care plans for long-term care members
• Educate members and families/caregivers on available services and benefits
• Evaluate member needs and available resources and recommend or facilitate plans for the best outcome
• Develop ongoing long-term care plans and identify providers, specialists, and community resources
• Coordinate between members/families/caregivers and care provider teams to ensure services are accessible
• Provide resource support for employment, housing, participant direction, independent living, justice, and foster care needs
• Monitor care plans, member status, and outcomes and recommend updates based on member needs
• Interact with long-term care healthcare providers and partners
• Collect, document, and maintain member information and care management activities for regulatory compliance
• Perform on-site visits as needed to assess member needs and collaborate with providers or resources
• Provide or facilitate education on procedures, healthcare provider instructions, service options, referrals, and healthcare benefits
• Provide leadership feedback on opportunities to improve quality of care and cost-effective service delivery
• Perform other duties as assigned
• Comply with all policies and standards

Medical Director

• Assist the Chief Medical Director in directing and coordinating medical management, quality improvement, and credentialing functions
• Provide medical leadership for utilization management, cost containment, and medical quality improvement activities
• Perform medical reviews for utilization review, quality assurance, and complex, controversial, or experimental services
• Support performance improvement initiatives for capitated providers
• Assist with planning goals and policies to improve quality and cost-effectiveness of care
• Provide medical expertise for quality improvement and utilization management programs
• Assist with physician committee structure, processes, and membership
• Conduct regular rounds for high-risk patients and coordinate with care management teams
• Collaborate with clinical teams, network providers, appeals teams, and medical and pharmacy consultants
• Participate in provider network development and new market expansion
• Develop and implement physician education regarding clinical issues and policies
• Identify utilization review studies, adverse utilization trends, unusual provider practice patterns, and benefit/payment adequacy
• Identify clinical quality improvement studies to reduce unwarranted variation in clinical practice
• Interface with physicians and providers to implement recommendations improving utilization and healthcare quality
• Review complex, controversial, unusual, or new-service claims for medical necessity and appropriate payment
• Develop provider-community alliances through medical management programs
• Represent the business unit before local and national publics, state committees, and ad hoc committees as needed

Pharmacist

• Define and develop standard and custom formularies for assigned plan
• Develop clinical criteria for medications
• Recommend plan design changes and clinical programs
• Monitor prior authorization requests
• Provide clinical support to internal departments and address clinical-related questions
• Ensure appropriate quality controls and initiate opportunities for performance improvement in pharmacy/practice
• Develop and implement programs designed to impact DUR for Medicaid and Medicare
• Develop, implement, and maintain pharmacy department policies and procedures
• Participate in coordination of the Medicare MTM program
• Assist the case management team with members, including clinical rounds presentations
• Contact providers regarding quality measures
• Ensure clinical criteria align with state guidelines
• Apply evidence-based findings to coverage policies and formulary decisions

Clinical Pharmacist – Quality

• Support administrative care management activities
• Perform outreach to members and providers by phone
• Answer inbound calls and serve as a point of contact for members, providers, and staff
• Schedule services
• Resolve member and provider issues, inquiries, requests, and concerns
• Support care-plan next steps, community and health-plan resource referrals, scheduling questions, and ongoing education
• Connect members with health-plan and community resources
• Explain care-plan procedures and protocols
• Support member onboarding and administrative duties, including sending welcome letters, correspondence, and educational materials
• Document and maintain non-clinical member records according to state and regulatory requirements
• Make referrals addressing Social Determinants of Health needs
• Comply with policies and standards and perform other assigned duties

Care Management Support Coordinator II

Authorization Specialist

• Act as a resource and support the prior authorization request process to ensure 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, including history, diagnosis and prognosis, for clinical reviewer determination
• Verify member insurance coverage and service/benefit eligibility using system tools
• Align authorizations with guidelines to support timely payment adjudication
• Perform data entry to maintain and update authorization requests in the utilization management system
• Process authorization requests according to the insurance prior authorization list and route them to appropriate clinical reviewers
• Remain up to date on healthcare authorization processes, policies and procedures
• Perform other duties as assigned
• Comply with all policies and standards

Authorization Specialist II

• Support care management activities and assigned member teams
• Perform member outreach by telephone and home visits
• Document care/service plans and related activities
• Coordinate care 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 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 and distribute them to providers as needed
• Identify needs and make referrals to Care Managers, community-based organizations, and Disease Managers
• Educate members about benefits and available resources
• Perform other assigned duties and comply with all policies and standards

Program Manager II – COB, TPL, Subrogation

Director, Quality Improvement – Digital Quality Measurement

Care Manager, RN

Program Manager II – Recovery Operations

Supervisor, Provider Data Management

Senior LTSS Service Care Manager, RN

Vice President – Strategic Initiatives

Program Manager III – SSBCI

LTSS Service Care Coordinator

LTSS Service Care Coordinator

Medical Director

Clinical Pharmacist – Quality

Care Management Support Coordinator II

Authorization Specialist II

Care Coordinator II