Centene Corporation

Position Purpose: To distribute incoming and outgoing correspondence Open, sort, prepare, and record incoming correspondence Scan all claims and documentation confidentially and timely File imaged claims, appeals, adjustments and inferior quality imaged claims appropriately Generate and mail correspondence related to submission errors Process all company outgoing mail Send Eagle claims in an accurate and timely manner on a daily basis Provide back-up for matching of repricing claims to factsheets Provide backup for front desk phone coverage in a courteous manner Lift totes weighing 35-40 pounds Education/Experience: High school diploma or equivalent. Clerical or related experience in a claims environment. Production related experience preferred. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color,...

Position Purpose: Compile and analyze financial information for the company. Lead various financial projects. Cost effectively manage the utilization of services and develop measures to track, trend and forecast related impacts of organizational strategic initiatives. Responsibilities: Run pre-established reports as well as development of new reports for internal stakeholders and regulatory agencies Develop metrics to evaluate financial impact of proposed contract and medical management Develop integrated revenue/expense analyses, projections, reports, and presentations Contribute commentary/insights into the business units performance based on market specific knowledge and analysis based results/indicators Create and analyze monthly, quarterly, and annual reports and ensures financial information has been recorded accurately Identify trends and developments in competitive environments and presents findings to senior management Perform financial forecasting and...

Position Purpose: Compile and analyze financial information for the company. Lead various financial projects. Responsibilities: Develop integrated revenue/expense analyses, projections, reports, and presentations Create and analyze monthly, quarterly, and annual reports and ensures financial information has been recorded accurately Identify trends and developments in competitive environments and presents findings to senior management Perform financial forecasting and reconciliation of internal accounts Handle complex and high level financial analysis Present and discuss analysis with upper management Education/Experience: Bachelor's degree in related field or equivalent experience. 4+ years of financial or data analysis experience. Advanced skills in Microsoft Excel. Healthcare experience preferred Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive...

Position Purpose: Serve as the claims payment expert for the Plan and as a liaison between the plan, claims, and various departments to effectively identify and resolve claims issues. Act as the subject matter expert for other Claims Liaisons. Analyze trends in claims processing issues and identify work process solutions Lead meetings with various departments to assign claim project priorities and monitor days in step processes to ensure the projects stay on track Assist in the writing work processes and continual auditing of the processes to ensure configuration, state mandates, benefits, etc. Review all Medicaid Bulletins for changes and updates and submit change requests (CRs) to update payment system. Audit check run and send claims to the claims department for corrections Identify any system changes and work notify the Plan CIA Manager to ensure its implementation Collaborate with the claims department to price pended claims correctly Document, track and resolve all plan...

Position Purpose : Serves as subject-matter expert on compensation related projects and provides support to management, recruiters and Human Resource Business Partners on compensation philosophy, policies, programs and processes. Implement and administer compensation programs including market pricing, updating/creating job descriptions, survey submissions and the annual event process. Plan, develop, implement and administer compensation programs to maintain competitive practices. Partner with HRBP's and internal clients to understand business needs, job requirements and organizational design to evaluate jobs. Assist with the creation and revision of job descriptions. Administer base pay and annual increase process. Ensures adherence in the determination of merit increases and consistency towards other salary adjustments, bonus targets and out of guideline situations. Conduct market and trend analyses through salary survey input and market intelligence/research on an ad hoc...

Position Purpose : Serves as subject-matter expert on compensation related projects and provides support to management, recruiters and Human Resource Business Partners on compensation philosophy, policies, programs and processes. Implement and administer compensation programs including market pricing, updating/creating job descriptions, survey submissions and the annual event process. Plan, develop, implement and administer compensation programs to maintain competitive practices. Partner with HRBP's and internal clients to understand business needs, job requirements and organizational design to evaluate jobs. Assist with the creation and revision of job descriptions. Administer base pay and annual increase process. Ensures adherence in the determination of merit increases and consistency towards other salary adjustments, bonus targets and out of guideline situations. Conduct market and trend analyses through salary survey input and market intelligence/research on an ad hoc...

Position Purpose :Analyze user requirements and issues, engaging closely with stakeholder to define requirements and ensure implementation of product vision. Own the end-to-end product strategy from concept to production. Gather feedback from operations teams and research industry trends to improve business systems processes Write and capture user stories and acceptance criteria to communicate clear product objectives and requirements Manage daily project goals and schedules ensuring features are clearly described, estimated and prioritized Collaborate with technical teams to build modular and reusable solutions, acting as the voice of the business users Simulate and test process systems improvements considering usability and industry standards Approve each feature and continuously communicate with technical and business teams to ensure adherence to product vision and to proactively evaluate risks Drive sprint and release plans and communicate changes to business teams...

Position Purpose: Assist in monitoring utilization of medical services to assure cost effective use of medical resources through processing prior authorizations. Initiate authorization requests for outpatient and inpatient services in accordance with the prior authorization list. Route to appropriate staff when needed. Verify eligibility and benefits Answer phone queues and process faxes within established standards Data enters authorizations into the system. Education/Experience: High school diploma or equivalent. 2+ years of customer service experience. Knowledge of medical terminology preferred. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

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. 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 Utilize assessment skills and discretionary judgment to develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs and promote desired outcomes 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 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...

Position Purpose: Assist in monitoring utilization of medical services to assure cost effective use of medical resources through processing prior authorizations. Initiate authorization requests for outpatient and inpatient services in accordance with the prior authorization list. Route to appropriate staff when needed. Verify eligibility and benefits Answer phone queues and process faxes within established standards Data enters authorizations into the system. Education/Experience: High school diploma or equivalent. 2+ years of customer service experience. Knowledge of medical terminology preferred. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Position Purpose: Assist the Vice President of Medical Affairs to direct and coordinate the medical affairs functions for the business unit. Oversee the denials and appeals department. May manage other medical directors. Assume VPMA responsibility in absence of VPMA. Provide medical leadership for all utilization management, pharmacy, case management, disease management, cost containment, and medical quality improvement activities. Perform medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services. Support the effective implementation of performance improvement initiatives for capitated providers. Assist VPMA in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. Provide medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state,...

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 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. Utilize knowledge, experience and discretionary judgment to develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs and promote desired outcomes 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 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...

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: Act as the liaison for all statewide appeals, fair hearings, review organizations, and other external type appeals. Responsible for ensuring that all appeal letters generated comply with both State and NCQA requirements. Review clinical information for all appeals utilizing nationally recognized criteria to determine medical necessity of services requested. Prepare reviews for cases that did not meet criteria Gather, analyze and report verbal and written information regarding member and provider clinical appeals, including information follow up Prepare response letters for member and provider clinical appeals and ensure letters are compliant with State and NCQA standards. Maintain files and logs for all appeals Coordinate with Medical Director(s) to clarify medical determinations or clinical rationale Maintain current knowledge of NCQA and State regulations Coordinate Fair Hearings with various internal departments and agencies Education/Experience: RN with...

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. 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 Utilize assessment skills and discretionary judgment to develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs and promote desired outcomes 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 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...

This position is a remote opportunity Position Purpose: The Utilization Review Nurse I provides first level clinical review for all outpatient and ancillary services requiring authorization. Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services. Answers Utilization Management directed telephone calls; managing them in a professional and competent manner. Processes all prior authorizations to completion utilizing appropriate review criteria. Identifies and refers all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Program Integrity. Acts as liaison between the TRICARE beneficiary and the Network Provider. Provides first level RN review for all outpatient and ancillary prior authorization requests for medical appropriateness and medical necessity using appropriate criteria, referring those requests that fail review to the...

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 Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate...

Position Purpose: Provide tactical and analytical support to leadership to analyze performance and ensure success of product lines within Centene and its portfolio of subsidiaries. Responsible for managing discreet information and components for corporate-wide initiatives related to Dual Demonstration, Long Term Services & Supports (LTSS) and Intellectual & Developmental Disabilities (IDD) products. May provide guidance and assistance to other team members. Conduct qualitative and quantitative analysis on product performance, competitive position, product innovation, and product development Lead various sub-projects and initiatives Identify required product modifications and enhancements Monitor and track industry demands and competitor enhancements Assist with product development strategy formulation Serve as product subject matter expertise for assigned states and team members Build trust-based relationships with peers within assigned health plans and across...

Position Purpose: Oversee all compliance functions for the health plan including communication and coordination of policy development. Oversee the accurate and timely submission of over contract deliverables for all lines of business and service delivery areas. Oversee the accurate and timely submission of all CMS Medicare SNP requirements Serve as senior leadership and single point of contact in all State compliance meetings and interactions. Manage direct correspondence and daily interaction with all state regulators. Serve as senior leadership in all Department of Insurance and HHSC audit processes. Managing all facets of the audit and communications. Serve as senior leadership in Enterprise Risk Management process working directly with corporate ERM and Executive Management team to ensure current evaluation and documentation of business risks. Conduct internal compliance audits, write corrective action plans and work with contract and department managers to ensure timely...