Centene Corporation

Position Purpose: Design, develop, distribute and maintain all business information related reporting, including the development of complex parameterized reports, potential integration with a web based interface and the design of enterprise dashboard solutions. Assist in the implementation of quality and information distribution standards and processes. Work closely with the Business to understand the functional needs of system users and translate those needs into system requirements and design for data warehousing and reporting. Direct the implementation of a consistent business intelligence strategy including regular reporting of Key Performance Indices (KPIs). Actively participate in the program management of the analytics staff and projects. Assist in the development and validation of all reporting. Oversee and ensure the quality of data and structure of the Reporting & Analytics Environment, including the monitoring of DBA (Doing Business As) activities. Assist in...

Position Purpose: Identify special needs members through the completion of health screens and other resources. Work with community outreach/member advocates to coordinate member care. Educate providers and community resources on program components and available support services. Educate members with special needs to foster compliance with program and positively impact outcomes. Conduct site visits as appropriate for programs and provide support to other special programs. Assist with modification and management of care plans under the direction of a Registered Nurse in conjunction with member, medical consenter or caregiver, Department of Family and Protective Services (DFPS) caseworker and family, if applicable, as well as the managing physician. Provide support to medical, behavioral and social support staff to determine needs, eligibility and services for members. Conduct screening and risk assessment interventions per program guidelines. Education/Experience:...

Position Purpose: Perform various analysis and interpretation to link business needs and objectives for assigned function. 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 Diagnose problems and identify opportunities for process redesign and improvement Attend daily State Production Tech Op calls as the main POC and serve as the subject matter expert on Service Now to provide the root cause analysis, resolution information and any applicable updates as needed for Service Now tickets that impacts Carolina Complete Health (CCH) due to file issues and technical issues. Provide support to the Advanced Medical Homes (AMH) Team to review the AMH Dashboard to make sure CCH...

Position Purpose: Responsible for the compliance program for Federal Services and for the Federal Services Compliance Committee. Ensure Federal Services is in compliance with all applicable federal program regulations, contract requirements and Centene Corporate policies. Responsible for maintenance and updates to a formal, documented Compliance Program covering all programs in Federal Services. Maintain and track laws and regulations, contract documentations, amendments, and various compliance measures. Develop policies, procedures, and processes to comply with federal law, contract requirements, and various standards. Oversee, administer, and implement fraud and abuse and HIPAA programs for Federal Services, including training and education, investigations, and reporting. Provide guidance to various departments regarding compliance issues and implementation of new compliance requirements with respect to regulatory and contract language. Conduct compliance audits develop...

Position Purpose: Provide health education and coaching to members tailored to issues identified within treatment and service plans Coordinate with various healthcare providers for diagnostics, ambulatory care, and hospital services Assist members with social determinants of health including access to exercise and healthy food Promote activities focused on the health of a patient and their community, including without limitation outreach, quality improvement, and patient panel management Coordinate community-based management of medication therapyProvide specialty service care coordination to beneficiaries. Ensure appropriate services are delivered by specialty providers and ensure continuity of care across services. Responsible for the total care plan, encompassing all services and plans related to beneficiaries. Provide case management complying with Conflict Free Case Management rules. Education/Experience: High school diploma or equivalent. Bachelor's degree in social...

Position Purpose: Interact with various cross functional groups, complete the required auditing and reporting related to credentialing delegation, and ensure adherence with NCQA requirements for credentialing Collaborate with the various departments to conduct the timely credentialing delegation audits for the corporate Develop the post-audit reports based on audit findings and communicate those to the delegated entities, corporate credentialing manager, as well as health plan personnel Ensure compliance with delegation monitoring and oversight requirements for credentialing functions Manage policies and procedures related to delegation maintenance in an annual basis Assist with Credentialing Committee activities, as necessary to comply with NCQA requirements Ensure successful delegation partnerships Identify process improvement opportunities that decrease cost, improve quality and increase efficiency within the department Assist with other related activities as...

Position Purpose: The Group Database Respresentative I is responsible for the successful installation of new accounts as they pertain to membership group level data and the on-going group renewal process. This position is a forward facing role that requires you to handle highly escalated situations professionally and effectively. The ideal candidate for this position has great attention to detail and great communication skills as well as, prior experience working in a high volume work environment. Responsibilities: Reviews the accuracy of routing Group Sales Notifications (GSN) and supporting documentation prior to loading group in ABS. Provides detailed feedback to Marketing and Underwriting regarding correctness and completeness of the GSN following established standards. Communicates with Marketing, Underwriting, and Contracts to obtain clarification or resolve problems in processing. Loads group level data and rates onto the ABS system for new and renewing...

Position Purpose: Perform duties related to the day-to-day operations of the Service Management functions for Foster Care members to achieve the highest possible levels of functioning and wellness by ensuring consistent, timely access to medically necessary behavioral health services. Monitor quality of care, assist with discharge planning. Work with Foster Care Members, Medical Consenters, Department of Family and Protective Services (DFPS) staff and providers to meet the behavioral healthcare needs of each foster care member's condition. Identify foster care members who may benefit from service management, conduct an assessment and develop, implement and monitor a healthcare service plan. Provide information to DFPS staff to facilitate development of the DFPS case plan. Update database regularly with most recent Service Management Plan of Care. Review information submitted by providers into the database to ensure material is appropriate and consistent with guidelines for...

Position Purpose: Perform onsite review of emergent/urgent and continued stay requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings Collaborate with various staff within provider networks and discharge planning team electronically, telephonically, or onsite to coordinate member care Conduct discharge planning Educate providers on utilization and medical management processes Provide clinical knowledge and act as a clinical resource to non-clinical team staff Enter and maintain pertinent clinical information in various medical management systems For New Hampshire and Massachusetts - home visits required Promote the quality and cost effectiveness of...

Position Purpose: Responsible for development and production of Medicare regulatory required materials to ensure compliance with State and Federal regulations and alignment with administrative policies. Position supports CNC Medicare Solutions portfolio nationwide with pre-sale and member enrollment materials. Responsible for the production of Medicare regulatory required materials, pre-sale materials, and post enrollment member materials, as directed. Ensures compliance with State and Federal laws, accreditation standards, internal operations, and products. Works within materials automation platform to generate and update materials. Performs audits of language and content to ensure accuracy and consistency with models and templates. Supports Senior Specialists and Managers with implementation of approved language updates and audit of such changes in Medicare materials. Develops errata documents when necessary. Participates in cross-functional committees to promote...

Position Purpose: Provide sales coverage and develop best possible market penetration for all products to present and prospective accounts in his/her assigned territory in accordance with company's policies and programs. Provide greater access to health insurance, by providing education and assistance to Medicare individuals. Distribute health education materials and arrange for health screenings. Provide Facilitated Enrollment, help facilitate the continuance of health insurance, and offer assistance with recertification. Identify prospective enrollees and determine eligibility for participation in the Advantage Medicare product Understand and apply all policies and procedures pertaining to: Disclosures and provisions of the Advantage Medicare product Enrollment and disenrollment Develop a presence in the local community to help generate enrollments Conduct home visits and personalized appointments as needed to complete the enrollment process Market Advantage on-site at...

Position Purpose: Monitor real time call flow and provide guidance and direction to behavioral health call center personnel to ensure call metrics and standards are met or exceeded according to operational policies and procedures. Coordinate and manage workflow processes during assigned call center shifts and escalate issues requiring real-time actions to designated supervisor. Analyze and advise supervisor of personnel and workflow issues and recommend suggestions or solutions. Develop and implement standardized processes in collaboration with supervisors that address callers' needs and enhance positive outcomes in the areas of customer service, quality standards, and contractual requirements. Assist in post training activities, act as a resource for staff questions and provide assessments of staff progress and competence to trainers. Perform concurrent quality audits and provide feedback and coaching on strategies to achieve improved performance. Experience/Experience:...

Position Purpose: Ensure team completes retrospective medical documentation reviews with demonstrated inter-observer agreement. Ensure processes are in place for consistent execution of policies and procedures for retrospective medical documentation reviews and to monitor and identify gaps in productivity. Ensure team completes retrospective medical documentation reviews with demonstrated inter-observer agreement. Ensure processes are in place for consistent execution of policies and procedures for the reviews. Communicate with providers regarding the review process or review outcomes. Perform regular activities to monitor and identify deficits in meeting productivity requirements. Work, in collaboration with clinical and non-clinical review team, to ensure seamless completion of reviews from start-to-end. Perform medical documentation reviews and other clinical tasks, as necessary. Education/Experience: Master's degree in Applied Behavior Analysis, Psychology, or...

Position Purpose: Create contracts and manage the contracting process for new business opportunities, prepare contract status and metric reporting, identify gaps and risks in contracting process, and assist with work assignments and training for temporary staff. Create contracts and manage contracting process utilizing the Emptoris Contract Management System to ensure that new business contract deadlines are met. Assist with work load assignment for temporary contract coordination staff. Maintain spreadsheets and databases; collect, track, prepare, compile, and distribute statistical data for daily and ad hoc reports. Interface with credentialing staff to ensure data and systems are in sync. Provide support to contract negotiators to ensure successful completion of contracting process. Identify gaps and risk in contracting process and coordinate with multiple departments to ensure contracting process is completed timely and accurately and within required established...

Position Purpose: Prepare shipments, accept deliveries and move packages from one area to another including large inventory. Sort incoming and outgoing mail and packages for distribution. This role also assists with general maintenance of pharmacies and building maintenance. Responsibilities: Unloading of inbound shipments, orderly stacking of products & supplies and, the picking and staging of outbound shipments. Coordinate movement of products to storage areas with proper equipment and efficiently stacks and stores the merchandise in the appropriate area. Assists with physcial inspections of warehouse condition and equipment and, prepares work orders for repair and requisitions for replacement of equipment. Pick up and move quantities of computer equipment, furniture, and other office equipment from office to office or building to building using carts and other small moving equipment. Responsible for packing shipments including boxing, labeling and preparing orders...

Position Purpose: Conduct screening and risk assessment interventions per program guidelines. Act as primary liaison for members and staff. Assist with aspects of the member's care, including referrals to community resources. Identify special needs members through the completion of health screens and other resources Work with community outreach/member advocates to coordinate member care Educate providers and community resources on program components and available support services Educate members with special needs to foster compliance with program and positively impact outcomes Conduct site visits as appropriate for programs and provide support to other special programs Develop and modify care plans in conjunction with member, member's family and managing physician Development of plan specific literature and education materials in conjunction with medical director and corporate oversight Education/Experience: Bachelor's degree in Social Work, Nursing, Health,...

Position Purpose: Assist with maximizing the effectiveness of scheduling, systems, performance metrics, data analysis, reporting and overall operational functions for all lines of business and all locations. Evaluate staffing adjustments and re skilling of agents as necessary to provide adequate phone coverage. Oversee and monitor real-time call activity at various call centers and make necessary staffing adjustments. Monitor agent productivity and provide feedback to management Develop and submit various reports, including detail forecasts, plans, schedules and performance, both in advance and in review. Identify, evaluate and report issues and differentiate between workflow, technical, external or staffing. Maintain tracking database, analyze trends and make recommendations to management Work directly with the department head on strategic planning and new business implementation and forecasting. Ensure team is aware of any upcoming changes and provide insight on the...

Position Purpose: Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care Develop, assess and adjust, as necessary, the care plan and promote desired outcome Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio economic needs of clients Develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs Provide patient and provider education Facilitate member access to community based services Monitor referrals made to community based organizations, medical care and other services to support the members'...

Position Purpose: Develop, implement and oversee the pharmacy benefit management program across multiple product lines in both centralized and regional environments with multiple locations. Ensure compliance with contractual guidelines of the corporation and health plans impacted by numerous regulatory agencies with complex and often conflicting requirements. Oversee the pharmacy operations for the business unit, including prior authorization, drug utilization review programs, lock in programs, and plan specific medical management initiatives Evaluate program performance and recommend to State on program changes that would result in improved costs and higher quality Formulate and administer related organizational policies and procedures, including pharmacy service quality, pharmacy utilization management and achievement of company goals for pharmacy and medical programs Responsible for developing and attaining pharmacy AOP initiatives and Per Member Per Month (PMPM) goal...

Position Purpose: The Inside Sales Representative, Medicare Programs, is responsible for taking inbound telephone inquiries and web inquiries from prospective members and placing outbound calls to prospective members in response to leads received. Inside Sales Representatives conduct sales presentations over the telephone that may result in telephonic enrollments, in-home appointments, seminar reservations, or a kit request with follow up call. Answers inbound prospective member calls and places outbound follow-up calls to prospective members. Handles web inquiries and responds through outbound calls or email. Handles inbound Medicare calls and presents plan options to callers to encourage prospective members to join a plan. May complete the sale telephonically. Follows up on leads by conducting outbound calls designed to encourage prospective members to join and existing members to remain with the plan. Refers leads to outside sales representatives for in-home appointments...