The Senior Director oversees the development and implementation of hospital provider contracting activities and manages complex negotiations with major hospital systems. They are responsible for developing network strategies, monitoring performance, and ensuring compliance with quality and process standards.
The Internal Auditor II will execute risk-based audits to evaluate controls, processes, and risk mitigation strategies across health plan operations. They will also communicate audit findings and recommendations to management while supporting emerging AI-related audit initiatives.
The role involves performing financial analysis, pricing, and risk assessment to support Value-Based Care initiatives. You will develop financial models, analyze healthcare datasets, and collaborate with stakeholders to track vendor performance and financial outcomes.
The pharmacist will manage pharmacy services, including dispensing medications, conducting drug utilization reviews, and providing patient counseling. They will also collaborate with clinical teams to resolve drug therapy issues and ensure accurate prescription processing.
The Associate Actuary conducts financial analysis, pricing, and risk assessment to project Medicare Advantage performance. They support quarterly forecasting, Medicare bid certification, and provide data-driven recommendations to shape business strategy.
The specialist is responsible for maintaining accurate provider data in information systems to ensure correct claims payment and directory accuracy. They also facilitate provider education, resolve data issues, and support cross-functional projects.
The clinician performs clinical reviews to assess the medical appropriateness of mental health and substance abuse services. They also conduct prior authorizations, concurrent reviews, and engage with providers to ensure quality care and efficient discharge planning.
The Medical Director provides clinical leadership for utilization management, quality improvement, and cost containment activities while coordinating care for high-risk patients. They also collaborate with clinical teams and providers to review complex medical necessity appeals and ensure compliance with regulatory and accreditation standards.
The Project Manager will plan, organize, and oversee complex projects while managing cross-functional teams to meet strategic objectives. They are responsible for the full project life cycle, including budget management, resource allocation, and maintaining detailed project documentation.
The clinician performs clinical reviews to assess the medical appropriateness of mental health and substance abuse services. They also identify outlier provider performance, conduct record reviews, and provide coaching to improve quality and efficiency.
The clinician performs utilization reviews of Applied Behavioral Analysis (ABA) services to ensure medical appropriateness and clinical effectiveness. They also analyze behavioral health data and interact with healthcare providers to improve the quality of care for members.
The clinician performs utilization reviews of Applied Behavioral Analysis (ABA) services to ensure medical appropriateness and clinical effectiveness. They also analyze behavioral health data and provide education to members and families regarding the utilization process.
The Clinical Review Nurse performs concurrent reviews to evaluate medical necessity, acuity levels, and appropriate care settings for members. They also collaborate with medical directors and healthcare providers to manage discharge planning and ensure high-quality care delivery.
The Care Manager develops and facilitates complex care management activities for members with mental and behavioral health needs. They conduct assessments, create personalized care plans, and coordinate with providers and community resources to ensure high-quality healthcare outcomes.
The Finance Analyst will compile and analyze financial information, manage forecasts, and support budget development. They are also responsible for performing month-end close activities and providing insight-driven analysis to support financial targets.
The Behavioral Health Care Manager develops, assesses, and facilitates complex care management activities for members with mental health and substance use needs. They coordinate care between members, families, and providers while maintaining documentation to ensure compliance with regulatory standards.
The Transition Specialist manages the coordination of care for members transitioning between healthcare services, including developing individualized care plans and conducting assessments. They also act as a resource for members and families while collaborating with providers to ensure safe and timely transitions.
The clinician performs utilization reviews for Applied Behavioral Analysis (ABA) services to ensure medical appropriateness and clinical effectiveness. They also analyze member data, interact with healthcare providers, and provide education to families regarding the utilization process.
The clinician performs utilization reviews for Applied Behavioral Analysis (ABA) services to ensure medical appropriateness and clinical effectiveness. They also analyze behavioral health data and interact with healthcare providers to improve the quality of care for members.
The manager will oversee operations and business strategy with a focus on No Surprises Act Independent Dispute Resolution processes. They will also perform data analysis to measure product effectiveness and lead process improvement initiatives to increase quality and efficiency.
The Senior Care Manager assesses, plans, and implements complex care management activities to ensure quality, cost-effective healthcare outcomes for members. They also collaborate with providers and caregivers to develop personalized care plans while providing education on disease processes and benefit options.
The Care Manager develops, assesses, and facilitates complex care management activities for members with mental and behavioral health needs. They coordinate care plans, identify community resources, and provide ongoing education to members and their families to ensure high-quality healthcare outcomes.
The Clinical Extern will shadow preceptors and participate in projects to gain hands-on experience within the Managed Care industry. They will learn clinical processes and services while following company guidelines and instructions provided by management.
Performs access reviews, role provisioning, and supports Identity and Access Management systems through troubleshooting and process automation. Collaborates with cross-functional teams to design, implement, and maintain secure, high-availability IAM solutions.
The Clinical Extern will shadow preceptors and participate in projects to gain hands-on experience in the Managed Care industry. They will learn about various clinical services and follow established procedures in accordance with company guidelines.
The Clinical Review Nurse performs concurrent reviews to evaluate medical necessity, resource consumption, and the appropriate level of care for members. They collaborate with healthcare providers and medical directors to ensure high-quality care and facilitate timely discharge planning.
Develops, assesses, and coordinates complex discharge plans for high-risk members to ensure a smooth transition from acute care settings. Facilitates communication between providers and families while maintaining accurate medical records and ensuring clinically appropriate care.
The Senior Business Process Consultant leads cross-functional initiatives and develops business cases to drive performance improvement and financial gains. They are responsible for organizing work teams, facilitating consensus, and ensuring end-to-end policy and process integrity.
Performs concurrent reviews to evaluate medical necessity, acuity levels, and appropriate care settings for members. Collaborates with healthcare providers and medical directors to manage discharge planning and ensure continuity of care.
Leads the enterprise change communications function by providing strategic direction and executive support for major transformation initiatives. Partners with HR and the Transformation Office to drive alignment, establish governance, and measure communication effectiveness.
Performs concurrent reviews to evaluate medical necessity, acuity levels, and appropriate care settings for members. Collaborates with healthcare providers and medical directors to ensure quality care and facilitate timely discharge planning.
The Care Coordinator supports care management activities by performing member outreach via phone or home visits to discuss and document care plans. They coordinate services with healthcare providers and community partners to ensure continuity of care and member satisfaction.
The Finance Analyst will compile and analyze financial information while managing quarterly forecasts and budget development. They are responsible for performing month-end close activities and providing insight-driven analysis to support financial targets.
The Senior Manager oversees system and business requirements for new and existing business to ensure compliance with health plan and provider contract standards. They are responsible for managing system configurations, reporting deliverables, and process improvements to enhance organizational efficiency.
The Care Manager develops and facilitates complex care management activities for members with mental and behavioral health needs. They coordinate care plans, collaborate with providers, and provide education to members and their families to ensure high-quality healthcare outcomes.
The Senior Manager oversees the maintenance of accurate financial records and leads financial analytic functions for inpatient claims. They are responsible for developing standardized review processes, preparing budgets and forecasts, and interpreting financial reports for senior management.
The Finance Analyst will compile and analyze financial information while leading various financial projects related to IT finance. Responsibilities include managing labor reporting, project costing, budget development, and ensuring financial controls and compliance.
Analyze extensive healthcare datasets to extract insights that influence business decisions and improve clinical outcomes. Collaborate with stakeholders to identify value, develop solutions, and automate processes while managing multiple data review tasks.
The Care Coordinator II supports care management activities by performing member outreach via phone or home visits to ensure continuity of care. They coordinate service plans, document member needs, and facilitate communication between healthcare providers, partners, and members.
The Supervisor of Operations provides direct supervision to staff, including hiring, training, and performance management to ensure operational objectives are met. They monitor workflow, analyze operational data, and develop policies to improve process efficiency and quality standards.
The Care Manager performs assessments, planning, and coordination of medical services for post-discharge members to ensure quality and cost-effective care. They also conduct medication reconciliation and facilitate transitions between primary care physicians, specialists, and other support resources.
The Public Programs Specialist resolves member access to care issues and coordinates services with specialized public agency programs. They also serve as a liaison to external agencies and manage complex service coordination cases to ensure effective healthcare delivery.
The specialist will identify and implement enterprise-wide process improvement activities using methodologies like Lean and Six Sigma to support business infrastructure. They are also responsible for monitoring project performance metrics and facilitating cross-functional improvement teams.
The National Medical Director assists in directing medical management, quality improvement, and credentialing functions while providing leadership for utilization management and cost containment. They also collaborate with clinical teams and providers to optimize patient outcomes and ensure compliance with regulatory and accreditation standards.
The Community Relations Specialist leads marketing and outreach activities to achieve membership and enrollment goals within the Dallas-Fort Worth area. They are responsible for developing business relationships, coordinating community events, and acting as a liaison for market materials and sales strategies.
The Program Manager will lead cross-functional teams to execute concurrent projects while identifying opportunities to improve efficiency and service levels. They are responsible for managing the full project lifecycle, including budget oversight, risk mitigation, and stakeholder communication.
The Care Coordinator II supports care management activities by performing member outreach via phone or home visits to ensure continuity of care. They coordinate care plans, document member needs, and facilitate communication between healthcare providers, caregivers, and community partners.
Support the development and maintenance of quality improvement projects specifically for HEDIS Hybrid Operations. Provide clinical support for medical record abstraction, over-read, and audit processes while training providers and staff on quality methodologies.
The Strategy & Planning Manager provides strategic, operational, and administrative support to the Population Health and Clinical Operations Executive. This role involves managing action plans, coordinating executive communications, and facilitating cross-functional projects to ensure organizational objectives are met.
The manager oversees program and project managers, providing leadership, guidance, and performance management across the project life cycle. They are responsible for resource planning, budget monitoring, stakeholder management, and developing team capabilities.
The Care Manager develops and facilitates complex care management activities to provide high-quality, cost-effective healthcare outcomes for members. They coordinate care plans, monitor member progress, and provide education to members and their families regarding disease processes and healthcare resources.
The Sales Representative will develop market penetration for Medicare products by conducting community outreach, home visits, and personalized appointments. They are responsible for identifying prospective enrollees, determining eligibility, and assisting members with health insurance enrollment and education.
The Creative Production & Communications Manager creates multimedia and communications materials while coordinating creative projects from intake through delivery. This role partners with stakeholders to ensure all deliverables align with brand standards and business objectives.
The Associate Quality Practice Advisor educates community physician practices on HEDIS measures, medical record documentation, and coding standards to ensure compliance. They also collect and analyze provider performance data to identify improvement opportunities and support clinical wellness initiatives.
Lead the development, implementation, and optimization of Medicaid benefit programs and vendor solutions throughout the product life cycle. Drive vendor strategy, performance management, and cross-functional collaboration to ensure compliant, scalable, and competitive benefit portfolios.
The Senior Medical Director will oversee clinical operations and provide strategic leadership for healthcare initiatives. They are responsible for ensuring high-quality patient care standards and regulatory compliance across the organization.
The coordinator assesses and develops holistic care plans for long-term care members while educating families on available services. They also monitor member outcomes and coordinate with healthcare providers to ensure accessible and cost-effective care.
The Senior IAM Engineer designs, develops, and implements enterprise identity and access management solutions while serving as a technical escalation point. They are responsible for leading technical integrations, troubleshooting complex system behaviors, and contributing to the future-state IAM architecture and roadmap.
The Vice President of Product Strategy oversees the product development function, including formulating product vision, strategy, and roadmaps aligned with company goals. They drive digital and data-driven innovation while managing complex priorities across various business units and strategic partners.
Conduct fraud, waste, and abuse investigations by analyzing claims data, medical records, and provider information to identify misconduct. Prepare detailed investigative reports and collaborate with internal and external stakeholders to support case resolution and program integrity.
The Provider Performance Manager collaborates with healthcare providers to implement operational and clinical process improvements to meet value-based contract goals. They are responsible for identifying performance metrics, developing action plans, and facilitating collaboration across provider groups to improve clinical outcomes.
The analyst is responsible for configuring, testing, and maintaining system tables to support accurate claims adjudication in a managed care environment. They also proactively identify opportunities for automation and resolve configuration-related system issues.
The coordinator assesses and develops holistic care plans for long-term care members while educating families on available services. They also monitor member outcomes and collaborate with healthcare providers to ensure services are accessible and compliant with regulations.
Leads an analytics engineering team in designing and optimizing scalable data models while bridging business needs with technical execution. Mentors team members, drives the adoption of modern data tools, and ensures data quality and AI-readiness across the enterprise.
The Market Research Strategist leads pilot initiatives and conducts meta-research to optimize research investments while serving as a subject matter expert for business partners. They synthesize qualitative and quantitative data to deliver actionable insights and strategic recommendations to senior leadership.
The Senior Trainer is responsible for developing and administering universal training curricula and auditing tools for various departments. They will conduct training sessions, evaluate program effectiveness, and implement improvements based on audit results.
The Director of Process Improvement will develop and implement business process excellence initiatives using Six Sigma/LEAN methodologies to address operational inefficiencies. They will also provide leadership for business unit implementations, ensuring projects meet budget, timeline, and contractual requirements.
Design, implement, and manage special population programs and community-based initiatives to improve member and provider outcomes. Act as a liaison between regional authorities and system partners while leading cross-departmental teams in performance improvement efforts.
The Health Benefit Representative educates and assists individuals with enrolling in various health insurance plans through the NY State of Health Marketplace. They also support existing members with renewals, benefit education, and community outreach activities.
The Senior Director oversees the development and implementation of contracting activities, network development, and optimization initiatives across multiple product lines. They are responsible for executing network strategies that support organizational growth, regulatory compliance, and provider engagement.
The Senior Compliance Analyst will assist in maintaining the corporate compliance program by performing regulatory reporting, conducting audits, and managing ethics projects. They will also serve as a liaison for regulatory agencies and provide guidance on compliance policies and procedures.
The Senior Compliance Analyst assists in maintaining the corporate compliance program by performing regulatory reporting, auditing, and risk assessments. They also lead special projects and serve as a liaison for regulatory agencies to ensure organizational adherence to state and federal mandates.
Conduct fraud, waste, and abuse investigations by analyzing claims data, medical records, and provider information to identify misconduct. Prepare detailed investigative reports and collaborate with internal and external stakeholders to support case resolution and program integrity.
Manage strategic vendor partnerships, including evaluation, contracting, and performance oversight to support clinical and operational objectives. Facilitate collaboration between vendors and internal departments while providing executive-level reporting on performance metrics.
The manager oversees vendor relationships and financial performance, including budget development, forecasting, and invoice management. They also lead cross-functional initiatives to ensure contractual compliance and operational efficiency.
The Care Coordinator II supports care management activities by performing member outreach, conducting assessments, and coordinating services with healthcare providers. They maintain member records in compliance with regulatory standards and facilitate continuity of care through ongoing education and resource referral.
The Vice President of Member Enrollment & Billing oversees regional billing and enrollment operations to ensure regulatory compliance and operational efficiency. This role involves developing strategic plans, managing departmental budgets, and fostering a high-performing team to drive revenue cycle excellence.
The trainer is responsible for developing and conducting training programs for pharmacy services staff while performing training needs analyses. They also assist in auditing work processes and presenting recommendations for improvement to management.
The advisor will develop and execute strategies for the Duals Integration Office while conducting research and analysis on policy proposals. They will also manage functional policy portfolios and communicate complex information to internal and external stakeholders.
The RN Supervisor oversees the utilization management team, including prior authorization and clinical review processes, to ensure compliance with quality and regulatory standards. They also provide coaching, training, and performance feedback to team members while collaborating with senior management on policy development.
The Senior Actuarial Analyst assists in financial analysis, pricing, and risk assessment to estimate outcomes and support business decision-making. They are responsible for building actuarial models, evaluating healthcare cost trends, and communicating findings to executive stakeholders.
The Contract Negotiator V leads complex provider and vendor negotiations to strengthen strategic partnerships and support organizational affordability goals. They are responsible for managing implementation, conducting financial analyses, and reporting on the performance of designated agreements.
The Senior Infrastructure Security Engineer manages Attack Surface Management and Breach Attack Simulation programs to validate security controls and reduce risk. They collaborate across departments to monitor vulnerabilities, remediate security alerts, and maintain robust application security standards.
The Director of Clinical Training oversees all training activities, including curriculum development, facilitation, and the evaluation of training effectiveness and ROI. They collaborate with subject matter experts and HR to implement learning initiatives that support succession planning, performance management, and organizational effectiveness.
The officer serves as a partner between enterprise stakeholders and risk management to translate regulatory and security requirements into operational controls. They facilitate cross-functional initiatives to ensure audit-ready compliance while enabling risk-informed business decisions across technology and operational environments.
Develops and coordinates holistic care management activities for members with significant mental and behavioral health needs. Acts as a liaison and advocate while performing regular site visits to assess needs and facilitate community resources.
The manager will lead a team to investigate fraud, waste, and abuse while ensuring compliance with state and federal regulations. They are responsible for monitoring business processes, preparing saving reports, and developing educational materials for the health plan.
The Vice President of Sales Operations leads sales reporting, data management, and systems oversight while managing broker incentive programs. They act as a senior liaison to sales leadership and cross-functional partners to drive sales goals and budget management.
The role involves acting as a SAS subject matter expert to design, program, and optimize complex business processes and database solutions. You will analyze operational procedures, conduct data analysis, and provide technical oversight to ensure project goals are met.
The Enterprise Engagement Lead Analyst translates complex regulatory and contractual requirements into actionable, risk-informed analysis to support privacy and security operations. They serve as a Second Line of Defense advisor, developing executive-ready insights and maintaining requirement traceability across the enterprise.
The role translates complex regulatory and contractual requirements into actionable, risk-informed analysis to support enterprise privacy and security. It serves as a Second Line of Defense advisory partner, developing executive-ready insights and ensuring regulatory requirements are operationalized across the organization.
The Enterprise Engagement Lead Analyst translates complex regulatory and contractual requirements into actionable, risk-informed analysis for the Privacy & Security team. They serve as a Second Line of Defense advisor, developing executive-ready insights and ensuring regulatory obligations are operationalized across the enterprise.
The Enterprise Engagement Lead Analyst translates complex regulatory and contractual requirements into actionable, risk-informed analysis for the Enterprise Privacy & Security Risk Management team. This role serves as a Second Line of Defense advisor, developing executive-ready insights and ensuring regulatory obligations are effectively operationalized across the enterprise.
The Enterprise Engagement Lead Analyst translates complex regulatory and contractual requirements into actionable risk-informed analysis for the Privacy & Security team. They serve as a Second Line of Defense advisor, developing executive-ready insights and ensuring regulatory obligations are effectively operationalized across the enterprise.
The Behavioral Health Medical Director assists in directing medical management, quality improvement, and credentialing functions while providing leadership for utilization review and cost-containment activities. They also collaborate with clinical teams to optimize care for high-risk patients and represent the business unit on medical policy matters.
The coordinator connects members to community resources and supports the care team by identifying support needs and providing health education. They conduct non-clinical assessments and outreach to help members navigate care services and resolve concerns.
The Lead Proposal Writer develops complex, high-scoring Medicaid RFP responses by collaborating with subject matter experts to translate policies into compelling narratives. They also serve as a functional area expert, mentor departmental staff, and manage project activities to support business growth.
The Vice President of Medicare Care Management leads the national organization to improve clinical outcomes, member experience, and medical cost performance. They are responsible for executing enterprise strategy, ensuring regulatory compliance, and driving operational excellence through standardized clinical practices.
The Care Manager develops and facilitates complex care management activities, including personalized care plans and education for members and their families. They also coordinate with providers and community resources to address unmet needs and ensure timely access to healthcare services.
The manager will oversee regulatory audits and examinations for a regional portfolio of Medicaid health plans while leading a team of audit coordinators. They are responsible for ensuring audit readiness, managing documentation, and presenting audit outcomes to leadership.
Lead the development and execution of business development strategies to expand ICHRA adoption and drive organizational growth. Build and maintain executive relationships with brokers, employers, and key stakeholders while overseeing market expansion initiatives.
The specialist leads the integrity and governance of corporate ethics and compliance programs while overseeing vendor relationships and contract lifecycles. They also manage regulatory updates and conduct audits to ensure adherence to government-sponsored healthcare program requirements.
Conduct fraud, waste, and abuse investigations by analyzing claims data, medical records, and provider information to identify misconduct. Prepare detailed investigative reports and collaborate with internal and external stakeholders to support case resolution and program integrity.
The Senior Director will develop and execute integrated multichannel marketing strategies to drive growth for the ICHRA insurance business. They will lead marketing teams and agency partners while fostering a data-driven, consumer-obsessed culture.
The Provider Quality Liaison connects with plan providers to share quality performance reports and collaborate on initiatives to improve HEDIS and member experience measures. They act as an ongoing resource for provider practices, resolving issues and developing action plans to support quality performance across various product lines.
The role involves designing, analyzing, and administering corporate benefit plans while managing carrier relationships and ensuring legal compliance. You will also research complex benefit issues, perform regulatory filings, and provide training to human resources staff.
The clinician performs clinical reviews to assess the medical appropriateness of mental health and substance abuse services. They conduct prior authorizations, concurrent reviews, and engage with healthcare providers to improve the quality and efficiency of care.
The Care Manager develops and facilitates complex care management activities, including personalized care plans and education for members and their families. They also coordinate with providers and community resources to address member needs and ensure high-quality, cost-effective healthcare outcomes.
Conduct fraud, waste, and abuse investigations by analyzing claims data, medical records, and provider information to identify misconduct. Prepare detailed investigative reports and collaborate with internal and external stakeholders to support case resolution and program integrity.
The Senior Manager is responsible for driving product performance across multiple lines of business by overseeing analysis, improvement initiatives, and strategic vision. They will collaborate with cross-functional leadership to manage cost structures and ensure the delivery of compliant, competitively priced products.
The Care Coordinator supports care management activities by performing member outreach via phone or home visits to facilitate care plans and ensure continuity of services. They coordinate with healthcare providers and community partners to address member needs, document care activities, and provide education on available resources.
The Vice President will lead the integration, modernization, and operational strategy of enterprise telephony and contact center platforms. They will collaborate with stakeholders to implement scalable, AI-driven solutions that enhance customer experience and operational efficiency across healthcare lines of business.
The Vice President provides strategic and operational leadership for enterprise interoperability, ensuring secure and seamless healthcare data exchange across systems and stakeholders. They are responsible for developing roadmaps, managing vendor partnerships, and ensuring compliance with federal and state interoperability requirements.
Leads the end-to-end strategy, development, and execution of product and operational capabilities for the ICHRA business. Partners with cross-functional teams to translate market insights into scalable, customer-centric solutions that drive business growth.
The Care Navigator assesses member needs to develop and coordinate personalized care plans while providing education and support to members and their families. They also facilitate access to community resources and collaborate with healthcare providers to ensure high-quality, cost-effective care outcomes.
The officer will translate privacy, security, and AI requirements into actionable enterprise controls while building relationships with health plan leadership. They are responsible for managing compliance evidence, audit readiness, and overseeing the accuracy of documentation across the organization.
The Care Manager develops and facilitates complex care management activities, including personalized care plans and education for members and their families. They coordinate with providers and community resources to address unmet needs while ensuring compliance with regulatory standards.
The Community Resource Coordinator supports members by connecting them to community and care resources to facilitate their care management journey. They also conduct non-clinical health and environmental assessments to assist the clinical team and ensure members receive appropriate support.
The Clinical Appeals Coordinator acts as a liaison for statewide appeals and fair hearings while ensuring all correspondence complies with State and NCQA requirements. They review clinical information to determine medical necessity and coordinate with Medical Directors to clarify clinical rationales.
The Quality Practice Advisor establishes relationships with physician practices to educate them on HEDIS measures, risk adjustment, and documentation standards. They also analyze performance data to identify improvement opportunities and support quality intervention strategies.
The Sales Representative is responsible for developing market penetration for Medicare products by educating prospective members and facilitating the enrollment process. They must maintain a strong local community presence, conduct home visits, and participate in outreach events to meet sales goals.
The Vice President will oversee the product development function, formulating vision and strategy for clinical technology portfolios while driving the deployment of AI-enabled capabilities. They will manage enterprise-wide roadmap priorities, vendor accountability, and ROI measurement to ensure scalable and compliant automation across clinical workflows.
The Senior Director will lead the process for identifying and obtaining business licenses while advising leadership on state-level regulatory trends. They are responsible for assessing the viability of requirements, coordinating application documentation, and managing cross-functional implementation plans.
The Care Manager develops and facilitates complex care management activities for members with mental and behavioral health needs, including creating personalized care plans. They also coordinate services between members, families, and providers while monitoring clinical outcomes and ensuring regulatory compliance.
The Medical Director assists in directing medical management, quality improvement, and credentialing functions while providing leadership for utilization management and cost containment. They also collaborate with clinical teams to optimize outcomes for high-risk patients and ensure compliance with regulatory and accreditation standards.
The Clinical Account Manager provides clinical expertise to clients to design effective benefit programs and optimize therapeutic outcomes. They also collaborate with internal teams to analyze drug utilization data and develop customized clinical business plans.
The Senior Care Manager assesses, plans, and implements complex care management activities to ensure high-quality, cost-effective healthcare outcomes for members. They also collaborate with providers and caregivers to develop personalized care plans while providing guidance and coaching to clinical new hires.
The LTSS Service Care Manager develops and coordinates holistic care plans to ensure quality, cost-effective healthcare outcomes for long-term care members. They also conduct site visits, educate families on available services, and maintain documentation to ensure compliance with regulatory standards.
Develops and facilitates complex care management activities to provide high-quality, cost-effective healthcare outcomes for members. Coordinates with providers and families to address unmet needs, monitor progress, and update personalized care plans.
Develops and maintains the organization's contract governance and vendor management oversight framework while conducting risk-based audits to ensure regulatory compliance. Provides leadership to a team of professionals and serves as a primary point of contact for vendor relationship managers regarding oversight requirements.
The Care Navigator develops and coordinates personalized care plans to improve healthcare access and outcomes for members. They provide psychosocial support and facilitate access to community resources while maintaining compliance with regulatory standards.
The Business Process Consultant leads large-scale, cross-functional initiatives focused on regulatory compliance, encounter quality, and operational process improvement. They are responsible for facilitating performance optimization, designing future business solutions, and driving consensus across multiple markets.
Develops and facilitates complex care management activities to provide high-quality, cost-effective healthcare outcomes for members. Collaborates with providers and families to create personalized care plans and address social determinants of health.
The Senior Director will build and execute the company's LTSS market position to drive revenue growth and new business opportunities. They will oversee proposal development, manage new business implementations, and cultivate relationships with key providers, regulators, and community leaders.
The Sales Representative will develop market penetration for Medicare products by conducting community outreach, home visits, and personalized appointments to facilitate enrollment. They are responsible for educating prospective members on benefits, assisting with eligibility, and maintaining compliance with regulatory marketing guidelines.
Manages the care management team and oversees the development of cost-effective healthcare outcomes for members. Ensures compliance with federal, state, and NCQA standards while providing guidance on complex cases and member escalations.
The Care Coordinator supports care management activities by performing member outreach, coordinating care plans, and serving as a liaison between healthcare providers and members. They also document member needs, facilitate service assessments, and ensure continuity of care in compliance with regulatory standards.
The specialist participates in the oversight of corporate ethics and compliance programs, conducting focused reviews and audits to ensure adherence to contractual and regulatory requirements. They collaborate with business owners and delegated subcontractors to drive remediation and assess compliance risks across various health care programs.
The Provider Engagement Account Manager maintains partnerships between the health plan and provider networks to ensure high-quality care delivery. They manage network performance through data-driven consultative approaches, resolve provider issues, and conduct regular in-person visits to support clinical practices.
The Care Coordinator II supports care management activities by performing member outreach via phone or home visits to engage members and discuss care plans. They coordinate services with healthcare providers and community partners to ensure continuity of care and member satisfaction.
Develops and coordinates personalized care plans to improve healthcare outcomes and access for members. Facilitates access to community resources and collaborates with healthcare providers to ensure timely and high-quality care.
The Care Coordinator supports care management activities by performing member outreach via phone or home visits to discuss care plans and service needs. They coordinate care activities with healthcare providers and community partners to ensure continuity of care and member satisfaction.
The manager is responsible for overseeing the ongoing credentialing and re-credentialing processes for healthcare providers. They will also supervise a team, establish work procedures, and ensure data accuracy and compliance.
Independently conduct comprehensive reviews of MS-DRG and APR-DRG coding and clinical documentation to ensure accuracy and compliance. Collaborate with the Medical Director on complex cases and contribute to strategic audit initiatives.
The Quality Practice Advisor fosters relationships with physician practices to educate them on HEDIS measures, risk adjustment, and documentation standards. They also analyze performance data to identify improvement opportunities and support quality intervention strategies.
The Senior Manager oversees and monitors internal and external cost recovery and cost containment initiatives to meet targeted project metrics. They also manage vendor relationships, develop annual budgets, and present reporting packages to senior management regarding cost avoidance opportunities.
Oversee prepay waste, abuse, and fraud reviews through coding, editing, and audit programs while ensuring adherence to state and federal regulations. Develop and implement internal payment integrity policies, interpret audit results for senior management, and lead compliance teams to streamline operational processes.
The Senior Manager oversees internal and external cost recovery and containment initiatives to meet targeted project metrics and savings goals. They also partner with health plans to identify cost-saving opportunities and present reporting packages to senior management.
Develops and facilitates complex care management activities to provide high-quality, cost-effective healthcare outcomes for members. Collaborates with providers and families to create personalized care plans while monitoring member status and addressing barriers to care.
The Senior Manager oversees and monitors internal and external cost recovery and cost containment initiatives to meet targeted project metrics. They also partner with health plans to identify cost-saving opportunities and present reporting packages to senior management.
The Senior Compliance Analyst partners with leadership to maintain D-SNP program compliance through regulatory interpretation, reporting, and auditing. They also serve as a liaison for regulatory agencies and lead special projects to ensure adherence to state and federal requirements.
Provide strategic legal advice and support for Centene's Medicare products, including Medicare Advantage and Part D. Manage regulatory compliance, contract negotiations, and provider disputes while partnering with cross-functional business leaders.
The Care Manager develops, assesses, and facilitates complex care management activities for members with mental and behavioral health needs. They coordinate care plans, collaborate with providers, and provide education to members and their families to ensure high-quality, cost-effective healthcare outcomes.
The pharmacist will manage specialized hemophilia therapies, ensuring accurate prescription processing and optimal patient treatment outcomes. They are responsible for conducting drug utilization reviews, providing patient education, and collaborating with clinical teams to maintain high-quality care standards.
The Care Coordinator II supports care management activities by performing member outreach via phone or home visits to engage members and discuss care plans. They coordinate services with healthcare providers and community partners to ensure continuity of care and member satisfaction.
The Care Coordinator supports care management activities by performing member outreach via phone or home visits to engage members and discuss care plans. They coordinate services with healthcare providers and community partners to ensure continuity of care and member satisfaction.
The LTSS Service Care Manager is responsible for coordinating long-term services and supports for eligible members. They will develop, implement, and monitor individualized care plans to ensure members receive appropriate care and resources.
The Care Coordinator II is responsible for managing patient care plans and coordinating services to ensure optimal health outcomes. They will act as a primary point of contact for patients, providers, and families to facilitate effective communication and resource navigation.
The Senior Director of Proposal Development oversees business development strategies, manages the proposal pipeline, and collaborates with cross-functional teams to drive company growth. They are responsible for leading proposal reviews, ensuring operational requirements are captured, and maintaining consistency across all corporate messaging.
The Medical Director assists in coordinating medical management, quality improvement, and credentialing functions while providing clinical leadership for utilization management and cost containment. They also collaborate with clinical teams and providers to optimize patient outcomes and ensure compliance with regulatory and accreditation standards.
The Medical Director assists in directing medical management, quality improvement, and credentialing functions while providing clinical leadership for utilization management and cost containment. They also conduct rounds for high-risk patients and collaborate with clinical teams to optimize care outcomes and ensure regulatory compliance.
Oversee provider contracting, network development, and provider relations functions to ensure organizational efficiency and regulatory compliance. Perform complex financial analyses to identify cost improvement opportunities and execute strategies for new and existing market expansions.
Provide national expertise and thought leadership regarding foster care treatment, service needs, and evidence-based practices. Lead the development of mental health assessment toolkits and facilitate training for clinicians across the national network.
Develops and coordinates personalized care plans to improve member health outcomes and access to services. Provides psychosocial support and collaborates with healthcare providers to ensure timely delivery of care.
Develops, assesses, and facilitates complex care management activities for members with mental and behavioral health needs. Coordinates care plans between members, families, and providers to ensure accessible, high-quality healthcare outcomes.
Develops, assesses, and facilitates complex care management activities to provide high-quality, cost-effective healthcare outcomes for members. Coordinates care plans, monitors member status, and collaborates with providers and families to address unmet needs and barriers to care.
The Senior Director leads analytic service delivery by aligning strategic objectives with tool development and managing cross-functional analytic teams. They partner with clinical and business leaders to drive data-informed decision-making, performance improvement, and value realization across the enterprise.
The Director oversees prepay waste and abuse reviews, including coding, editing, and audit programs to ensure regulatory compliance. They are responsible for developing action plans, interpreting audit results, and leading teams to reduce fraud and improve operational processes.
The Sales Representative will develop market penetration for Medicare products by conducting community outreach, home visits, and personalized appointments. They are responsible for educating prospective members, facilitating enrollment, and ensuring compliance with all regulatory marketing guidelines.
Develops, assesses, and facilitates complex care management activities for members with mental and behavioral health needs. Coordinates care plans between members, families, and providers to ensure high-quality, cost-effective healthcare outcomes.
Leads the strategic direction and development of SIU capabilities to detect and prevent fraud, waste, and abuse within healthcare programs. Manages analytics personnel and collaborates with cross-functional stakeholders to drive data-informed strategies and actionable intelligence.
The Quality Improvement Coordinator II conducts compliance reviews of delegated entities, performs medical record audits, and investigates quality of care complaints. They also act as a liaison between community resources and the company while developing corrective action plans and reporting on clinical initiatives.
Direct provider network and contracting activities while establishing the department's strategic vision and objectives. Oversee network development staff, manage budgeting initiatives, and lead contract analysis to support market expansion and M&A activities.
Develops and coordinates personalized care plans to improve healthcare outcomes for members. Provides psychosocial support and connects members with necessary community resources and healthcare providers.
The analyst will support the development, governance, and implementation of organizational policies while managing regulatory filings and compliance workflows. They will also conduct audits, risk assessments, and provide guidance on compliance issues to ensure adherence to corporate and regulatory standards.
The Senior Director of Pharmacy manages pharmacy operations, develops benefit management programs, and establishes strategic vision across multiple markets and products. They are responsible for overseeing pharmacy utilization, contract administration, budget planning, and leading pharmacy department staff.
The Vice President of Finance provides leadership and proactive management for all FP&A and G&A activities, including developing the Annual Operating Plan and monitoring financial performance. They are responsible for identifying medical cost trends, overseeing pricing models, and providing strategic financial guidance to senior management.
The Senior Compliance Investigator leads and oversees enterprise-wide compliance and ethics investigations across all business units and health plans. This role involves assessing allegations, conducting witness interviews, performing root cause analysis, and recommending remedial actions to mitigate risks.
The Senior Director will oversee the Gold Card Program, ensuring effective performance and communication of strategic priorities to stakeholders. They will lead long-term program development initiatives and ensure the integration of adaptive technology and expert team-based services across business units.
The Senior Director leads enterprise-wide Prior Authorization governance strategy, oversight, and optimization across all lines of business. They collaborate with cross-functional teams to ensure programs are clinically appropriate, operationally efficient, and compliant with regulatory requirements.
The Lead IAM Engineer will design, build, and maintain scalable identity and access management solutions while leading cross-functional teams through implementation processes. They are responsible for enforcing identity lifecycle management policies and troubleshooting complex security-focused IAM issues.
The Care Coordinator supports care management activities by performing member outreach, conducting home visits, and documenting care plans. They coordinate services with healthcare providers and community partners to ensure continuity of care and member satisfaction.
The Program Manager leads large-scale, cross-functional initiatives for Gold Card programs, overseeing planning, execution, and operational readiness. They are responsible for managing budgets, risks, and dependencies while providing executive-level reporting and ensuring regulatory compliance.
Supervise and coordinate the daily activities of the Coding & Clinical Review team to ensure accurate DRG assignment, clinical validation, and audit outcomes. Monitor team performance, provide guidance on complex coding determinations, and implement departmental strategies to improve operational efficiency and quality.
Supervise and coordinate the daily activities of the Coding & Clinical Review team to ensure accurate DRG assignment, clinical validation, and audit outcomes. Monitor team performance, provide guidance on complex coding matters, and ensure compliance with regulatory and organizational standards.
Provide strategic leadership and oversight for the health plan compliance program, including regulatory strategy, policy development, and cross-functional implementation. Serve as the senior compliance leader for state interactions, audits, and risk management activities across the New Jersey market.
The Medical Director assists in directing and coordinating medical management, quality improvement, and credentialing functions for the business unit. They provide medical leadership for utilization management, cost containment, and collaborate with clinical teams to optimize outcomes for high-risk patients.
The Medical Director assists in directing and coordinating medical management, quality improvement, and credentialing functions for the business unit. They provide medical leadership for utilization management, cost containment, and collaborate with clinical teams to optimize patient outcomes.
The Medical Director directs medical management, quality improvement, and credentialing functions while providing leadership for utilization review and cost containment. They perform medical reviews of complex cases and collaborate with clinical teams to optimize outcomes for high-risk patients.
Lead the transformation of business strategy by designing solutions and estimating value realization for organizational initiatives. Partner with senior leadership to create business architecture models and maintain governance across delivery groups.
Executes the enterprise-wide Incident Response Plan and implements security service audit schedules to identify shortfalls. Collaborates with security architects and engineers to integrate third-party threat reporting into internal CIRT systems.
Direct and coordinate medical management, quality improvement, and credentialing functions to optimize member care and cost-effectiveness. Perform medical reviews of complex cases and provide leadership for utilization management and regulatory compliance.
Direct and coordinate medical management, quality improvement, and credentialing functions to optimize care for members. Provide medical leadership for utilization review and cost containment while collaborating with clinical teams and providers.
Directs medical management, quality improvement, and credentialing functions to optimize care and cost-effectiveness for members. Performs complex medical reviews and provides leadership for utilization management and medical necessity appeals.
Translate Medicare Advantage and Medicaid Risk Adjustment business requirements into technical specifications and production-ready SAS and Snowflake solutions. Modernize legacy ETL workflows into scalable Snowflake architecture while ensuring data quality and regulatory compliance for CMS audits.
Develops and facilitates complex care management plans for members with mental and behavioral health needs. Coordinates between members, families, and providers to ensure access to cost-effective healthcare and community resources.
Directs long-term care management for members with physical and behavioral health needs to ensure high-quality, cost-effective outcomes. Leads the design, implementation, and growth of LTSS programs while overseeing staff caseloads and regulatory compliance.
The Psychologist Reviewer will authorize, direct, and monitor care for behavioral health and substance abuse problems. They will conduct peer reviews and interact with network practitioners to provide education on best practices.
Leads a team of regulatory analysts to translate complex privacy, security, and AI requirements into actionable risk-informed analysis for the organization. Partners with Enterprise Engagement Officers to drive contract analysis, readiness reviews, and continuous improvement of compliance frameworks.
Translates privacy, security, and AI requirements from contracts and laws into actionable enterprise controls. Builds relationships with leadership to ensure compliance reporting, audit readiness, and continuous improvement across health plans.
Leads the day-to-day operations of a team of Sales Investigators to investigate misconduct by agents, brokers, and agencies. Ensures all investigative work is documented defensibly and aligns with internal policies, CMS requirements, and regulatory expectations.
The role involves managing the corrections process by triaging non-compliance issues and coordinating remediation efforts using GRC tools. It requires collaborating with stakeholders to develop corrective action plans and providing trend analysis for senior leadership.
Investigate allegations of healthcare fraud, waste, and abuse through claims audits and data analysis. Prepare detailed investigative reports for referral to state and federal agencies.
Investigate allegations of healthcare fraud, waste, and abuse through claims audits and data mining. Prepare detailed investigative reports for referral to state and federal agencies and coordinate resolutions with health plans.
Accountable for the Medical Loss Ratio (MLR) compliance and reporting program, ensuring accurate calculations and timely federal and state filings. Leads cross-functional alignment and provides strategic oversight of MLR methodology, governance, and regulatory examinations.
Lead and oversee Payment Integrity initiatives focused on potentially preventable readmissions, cost recovery, and payment accuracy. Manage a team of auditors and clinical professionals to ensure compliant determinations and alignment with regulatory requirements.
Direct provider network strategy and contracting activities, including access analysis and reimbursement management. Lead the development of provider networks across expansion markets and oversee budgeting and forecasting for network costs.
Investigate allegations of healthcare fraud, waste, and abuse through claims audits and data analysis. Prepare detailed investigative reports for referral to state and federal agencies.
Lead and manage complex, high-impact internal investigations to ensure adherence to federal and state regulations and internal ethical standards. Act as a strategic advisor to senior leadership by analyzing records, conducting interviews, and recommending remedial actions to mitigate risk.
The Utilization Review Clinician performs reviews of members' care and health status related to Applied Behavioral Analysis (ABA) services to determine medical appropriateness. They monitor clinical effectiveness and efficiency of care in accordance with ABA guidelines and provide education to members and their families regarding the utilization process.
Directs the organization with critical information for fact-based decisions and manages business and reporting analysts to produce operational reports. Leads the execution of projects based on predictive analytics and collaborates with various teams to provide effective reporting solutions.
Identify market trends and oversee functions of quality improvement programs. Collaborate with stakeholders to analyze business issues and recommend solutions for performance improvements.
Develop and facilitate complex care management activities for members, focusing on physical and mental health needs. Collaborate with providers and community resources to create personalized care plans and ensure members receive appropriate care.
The Utilization Review Clinician performs clinical reviews and assesses care related to mental health and substance abuse. They monitor and determine the appropriateness of care levels and services, ensuring they meet medical guidelines.
The Care Coordinator II supports care management activities and ensures services are delivered by healthcare providers. They interact with members through outreach and coordinate care activities based on care plans.
Supports care management activities and ensures services are delivered by healthcare providers. Engages members through outreach to discuss care plans and coordinates care activities as needed.
The Trainer I is responsible for developing and conducting training programs for Member and Provider Service roles in Centene’s contact centers. This includes conducting training needs analyses, evaluating training effectiveness, and assisting in auditing staff work.
The RN Clinical Review Nurse performs concurrent reviews to evaluate the necessity and appropriateness of care being delivered to members. This includes collaborating with healthcare providers and contributing to discharge planning according to established guidelines.
Supports administrative care management activities including outreach, answering calls, and scheduling services. Acts as a point of contact for members and providers to resolve issues and document member records.
Perform day-to-day functions to maintain provider databases and create reports to monitor network compliance with state requirements. Provide general administrative support of the assigned department.
Design and implement instructional strategies that support learning and performance for providers, caregivers, and external stakeholders. Oversee maintenance of training resources and support sites while developing instruments to assess individual change in knowledge and skills.
