Centene Corporation

Supervisor

• Supervise Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team
• Supervise day-to-day activities of the utilization management team
• Monitor and track UM resources for performance, compliance, quality, and efficiency
• Collaborate with the utilization management team to resolve complex care member issues
• Maintain knowledge of utilization management regulations, accreditation standards, and industry best practices
• Identify process and quality improvement opportunities with the utilization management team and senior management
• Educate and provide resources to the utilization management team
• Monitor clinical review nurses and ensure compliance with applicable guidelines, policies, and procedures
• Develop and implement UM policies, procedures, and guidelines with senior management
• Evaluate team performance and provide feedback on performance, goals, and career milestones
• Coach and guide the utilization management team
• Assist with onboarding, hiring, and training team members
• Lead and champion change within scope of responsibility
• Perform other duties as assigned
• Comply with all policies and standards

Supervisor, Utilization Management – RN

Quality Specialist

• Take a lead role in developing and maintaining quality improvement projects specific to HEDIS Hybrid Operations
• Serve as primary owner for assigned HEDIS measures
• Train providers, health plans, and staff in continuous quality improvement methodologies and tools, HEDIS abstraction, and over-read processes
• Provide clinical support to medical record abstraction, over-read, and audit processes
• Monitor performance on established contractual quality indicators
• Analyze, track, and trend results
• Prepare for and participate in meetings with committees, state agencies, providers, health plans, vendors, and stakeholders
• Recommend, develop, and implement quality performance improvement plans (PIPs) with management using the PDSA model
• Monitor and report PIP progress through closure
• Conduct year-round pseudo-claims performance, gap identification, and intervention and strategy planning for assigned HEDIS measures
• Support department leadership in project and strategy development
• Lead complex or high-risk HEDIS quality improvement initiatives with market-wide impact
• Provide guidance on complex abstraction scenarios, team training, measure interpretation, abstraction standards, and quality improvement best practices
• Mentor and serve as a resource to team members
• Perform other duties as assigned
• Comply with all policies and standards

Quality Improvement Specialist – HEDIS II

Program Manager

• Lead large-scale, cross-functional projects for implementation, migration, and process improvement
• Oversee program planning, management, and execution, including scope, schedule, budget, and resources
• Create comprehensive timelines and ensure project teams maintain deliverables and follow project management standards
• Drive enterprise telephony and contact center transformation initiatives, including AWS Connect migration programs
• Coordinate project managers and business analysts managing individual workgroups across Operations, Finance, Benefit Operations, and other functions
• Create executive dashboards, project status updates, and ongoing post-implementation analytics reports
• Create and deliver best practices and training information to indirect reports, peers, and employees
• Partner with training teams to create and review training materials
• Prepare and deliver documents for Program Steering Committees and the Executive team
• Assess program risks and escalate issues to leadership as needed
• Manage risks, budgets/forecasts, dependencies, and strategic analyses of business or operational opportunities
• Serve as the first escalation point for project issues and risks
• Resolve issues with project teams and create risk mitigation plans
• Communicate business and technology issues and solutions effectively

Program Manager IV – AWS Connect, Telephony

Compliance

• Research and analyze Medicaid, healthcare, legislative, contractual, and related regulations
• Serve as liaison with the state Medicaid regulator
• Coordinate incoming and outgoing regulatory communications
• Oversee complex audit deliverables and coordinate timely review and submission of regulatory deliverables
• Identify laws and regulations affecting health plan operations, including Medicare, Medicaid, ACA, CMS, and state Medicaid agency requirements
• Review legislative bills for impact to health plans
• Draft and issue summaries of regulatory updates
• Respond to non-routine regulatory inquiries from internal stakeholders
• Coordinate cross-functional meetings and track operational implementation of regulatory requirements
• Collaborate with internal and external teams, legal, and regulatory resources on legal, contractual, and regulatory issues
• Conduct ad hoc research and disseminate guidance
• Draft regulatory operations policies, procedures, and job aids
• Participate in external meetings with state agencies and stakeholders and document discussions, action items, and follow-up activities

Regulatory Analyst

Data Analyst

• Generate, analyze, report, and interpret financial and other organizational data
• Analyze financial trends and support financial reporting and business decision-making
• Lead financial data analysis projects
• Develop integrated revenue/expense analyses, projections, reports, and presentations
• Create and analyze monthly, quarterly, and annual reports
• Support accurate financial reporting and accrual analysis
• Identify financial trends and developments, analyze underlying drivers, and present findings to leadership
• Perform financial forecasting and reconciliation of internal accounts
• Support business initiatives through data analysis, identification of implementation barriers, and user acceptance testing of systems
• Diagnose problems and identify opportunities for process redesign and improvement

Financial Data Analyst III

Controller

• Assist with the management of the financial affairs for all health plans
• Assist with preparation of monthly financial analyses of operations for management guidance
• Assist with preparation of reports outlining the company’s financial position in income, expenses, and earnings
• Assist with preparation of statutory reports
• Monitor business processes and systems to assure integrity in health plan financial reports and information
• Monitor systems of internal accounting control in compliance with GAAP and/or SSAP and Company policies and standards
• Assist in arranging audits of the health plan’s accounts
• Provide financial and business analysis as required
• Convey health plan needs to appropriate parties for coordinated action
• Help develop, implement, and monitor program results
• Lead two direct reports and provide significant exposure across Finance and operational business teams

Assistant Plan Controller

Operations

• Oversee operations and business strategy using cross-functional departments to meet strategic objectives
• Develop and manage methodologies for tracking, identifying, and solving issues
• Interpret and present program results and insights
• Develop data-driven analysis approaches for clients
• Perform data analysis from various data sources to evolve effectiveness and return-on-investment metrics
• Collaborate with staff to identify internal and external customers and their expectations
• Initiate process changes to increase quality, decrease costs, and improve staff, provider, and member satisfaction
• Facilitate and support operations staff in planning, achieving, and tracking key strategic initiatives
• Serve as an internal resource and advisor on improvement activities
• Explore new work-process approaches using quality-improvement techniques to eliminate waste and re-work

Operations Manager

Clinical Operations

• Identify training needs to enhance performance, quality, and motivation of corporate and field staff for the Quality department
• Develop, conduct, and evaluate the effectiveness of training programs
• Manage activities related to training and educational programs for the Quality department
• Assess and identify individual or group training needs
• Prepare training aids and materials
• Determine whether to contract with outside vendors to accomplish training goals and objectives
• Analyze training program effectiveness and submit reports and recommendations to management
• Prepare and approve budgets and travel plans

Manager, Clinical Quality Training

• Ensure regulatory compliance with Washington state and other government agencies related to the health insurance industry, Centene Corporation, and its business subsidiaries
• Ensure Washington health plan and Centene Corporate comply with state and federal program regulations, insurance regulations, regulatory requirements for business entities, and state contract requirements
• Maintain and track laws and regulations, contract documentation, amendments, and compliance measures
• Develop policies, procedures, and processes to comply with state law, federal law, contract requirements, and standards
• Oversee, administer, and implement compliance programs, including fraud and abuse and HIPAA
• Advise departments on compliance issues and implementation of new compliance requirements
• Conduct compliance audits and develop and implement corrective action plans
• Report achievement of corrective action plans to senior management and Board of Directors
• Develop strategic relationships with state legislative policymakers
• Assist with state legislative public policy concerning state insurance, Managed Care Organization, Medicare, and Medicaid regulations and initiatives
• Identify, evaluate, and analyze the impact of state legislative and regulatory issues
• Advise management concerning legislative and regulatory impact
• Represent senior management at committees, meetings, and seminars
• Perform other duties as assigned
• Comply with all policies and standards

Compliance Officer

General

• Support members in connecting to community and care resources cost-effectively
• Coordinate community outreach resources and promote awareness of care and services
• Respond to member inquiries about community and care resources
• Support member correspondence and educational materials
• Document and maintain community resources according to health plan requirements
• Assist nurses and social workers with outreach, community education, informal guidance, and member support
• Conduct non-clinical general health assessments and refer members to appropriate care or services
• Conduct non-medical assessments covering home safety, community/environment resources, transportation, employment, and related needs
• Conduct telephonic and in-person outreach to locate hard-to-reach individuals and families
• Visit individual homes and community organizations as needed
• Perform other assigned duties and comply with policies and standards

Community Resource Coordinator II

• Provide consultative support to providers to improve performance on member outreach, utilization management, cost, quality and risk
• Discuss, analyze and interpret performance reporting, member engagement data and other data resources to identify opportunities for improving member outcomes
• Interpret performance data and prioritize insights
• Develop discussion and presentation documents, including year-to-date results, month-over-month performance and member engagement results
• Facilitate provider discussions regarding quality, utilization, cost or risk performance improvement opportunities using corporate tools and reporting
• Collaborate with the health plan quality counterpart to ensure coordinated communication and goal alignment for provider discussions
• Develop proficiency in tools and value based performance (VBP) and educate providers on tool use and data interpretation
• Present detailed HBR (Health Benefits Ratio) analysis and create reports for Joint Operating Committee meetings
• Perform other duties as assigned
• Comply with all policies and standards

Provider Performance Specialist II

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 according to regulatory guidelines and criteria
• Perform concurrent reviews of behavioral health inpatient care
• 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
• Collaborate with medical directors and leadership to improve care quality and efficiency
• Formulate and present cases in staffing and integrated rounds
• Comply with policies and standards
• Perform other assigned duties

Utilization Review Clinician – Behavioral Health

Pharmacist

• Process and review prior authorization requests for non-formulary medications for clinical appropriateness
• Review completed prior authorization requests and pharmacy technician recommended denials, formulary alternatives, comments, and attachments
• Verify member identification, date of birth, eligibility, carrier and group information
• Check previous prior authorization decisions and verify prescription and health plan benefit coverage
• Evaluate prescription claim history, chart notes, lab values, provider specialty, and medical policy criteria
• Determine whether requests meet approval criteria using case-by-case professional clinical judgment
• Review medication requests not addressed by P&T Committee criteria or guidelines and develop and draft criteria
• Research and contribute drug references and clinical information for prior authorization review
• Communicate with physicians and pharmacy technicians regarding non-formulary drugs, benefits, exclusions, quantity limits, age restrictions, and formulary alternatives
• Retrieve, collect, and compile data for reporting purposes
• Audit pharmacy claims greater than $200.00
• Suggest additions or deletions to the formulary and update quantity/day or age-limit entries
• Support the National P&T Committee
• Perform other related duties as needed

Clinical Pharmacist

Actuary

• Conduct strategic analysis, pricing, and peer review
• Build and support tools for planning processes and risk assessment
• Manage actuarial needs and produce actuarial reports supporting corporate strategy
• Contribute to Medicare strategic initiatives and planning
• Own and build tools and processes supporting internal users
• Review and certify Medicare Advantage bids when eligible for American Academy of Actuaries membership
• Calculate financial outcomes using mathematics, probability, statistics, finance, and business principles
• Develop probability tables and regressions from statistical data
• Research and analyze the impact of legislative changes
• Analyze and evaluate required premium rates
• Assess cash reserves and liabilities for future benefit payments
• Analyze data reports, identify trends and gaps, and recommend action
• Determine equitable bases for distributing insurance benefit funds
• Create and update actuarial reports
• Participate in merger and acquisition analysis
• Perform other assigned duties and comply with policies and standards

Associate Actuary

• Make outbound or receive inbound calls from members to schedule doctor appointments
• Assist members with completing Health Needs Screenings or making payments to become eligible for enhanced benefits
• Educate members on enhanced services and recommend preferred providers
• Educate members on appropriate Emergency Department utilization and its impact on benefits
• Identify and overcome barriers to completing health screenings, obtaining services, or making payments
• Review member profiles before outreach to identify opportunities and additional benefit eligibility
• Participate in continuous quality improvement initiatives
• Review and analyze call-report data and adjust call approaches
• Act as a secondary resource for Member Services or Provider Services call centers