The Vice President will lead the national Medicare Care Management organization, developing and executing strategies to improve clinical outcomes, member experience, and medical cost performance. They are responsible for overseeing Model of Care compliance, driving operational excellence, and fostering innovation through digital engagement and AI-enabled clinical 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 Community Resource Coordinator supports members by connecting them to community resources and facilitating their care management journey. They conduct outreach, perform non-clinical health assessments, and provide education to help members access necessary support services.
The Data Analyst III is responsible for managing complex data projects, including healthcare claims audit sampling, executive reporting, and dashboard development. They will also support automation and AI initiatives while mentoring other analysts and ensuring data quality through structured reconciliation.
The Care Navigator develops and coordinates personalized care plans to improve healthcare outcomes for members. They also provide psychosocial support and facilitate access to community resources while maintaining compliance with regulatory standards.
The position provides leadership for clinical, quality, and risk adjustment functions while developing programs to improve member care and reduce costs. It also involves analyzing performance trends, managing staff, and ensuring compliance with regulatory and contractual requirements.
The Director leads the strategy and execution of communications and change management initiatives to support the enterprise transformation portfolio. They partner with leadership to drive organizational readiness, culture alignment, and the adoption of strategic transformational changes.
The specialist will support quality improvement projects, conduct medical record audits, and analyze reporting results to track trends. They are also responsible for developing quality improvement plans and training providers on relevant methodologies.
The Senior Business Solutions Strategist leads business strategy transformation by identifying improvement opportunities and designing effective solutions. They coordinate across business groups to manage project scope, establish architecture governance, and advise senior leadership on strategic outcomes.
Perform detailed analysis to link business needs with objectives and support business initiatives through data analysis and user acceptance testing. Identify and analyze user requirements to improve existing processes and lead problem-solving efforts between business units.
The Quality Improvement Project Manager coordinates and monitors quality improvement projects, including NCQA and HEDIS preparation, from inception to closure. They are responsible for analyzing data, managing project deliverables, and implementing interventions to improve health measures.
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 analyst will perform data analysis to link business needs with objectives and lead problem-solving efforts between business units. They are responsible for identifying implementation barriers, conducting user acceptance testing, and recommending solutions to improve existing processes.
The Quality Improvement Project Manager coordinates and monitors quality improvement projects, including NCQA and HEDIS preparation, from inception to closure. They are responsible for analyzing data, managing project documentation, and facilitating interventions to improve health measures.
The Payment Integrity Business Partner serves as a primary liaison between health plans, providers, and vendors to ensure payment accuracy and operational effectiveness. They facilitate issue resolution, communicate program performance, and manage cross-functional initiatives across various lines of business.
The clinician performs utilization reviews of Applied Behavioral Analysis (ABA) services to ensure medical appropriateness and clinical effectiveness. They also interact with healthcare providers, provide education to families, and contribute to process improvements for behavioral health services.
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 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 Senior Quality Improvement Specialist coordinates regulatory, accreditation, and clinical quality programs to ensure compliance with state and federal requirements. They lead complex health services initiatives, manage vendor oversight, and develop strategies to improve HEDIS and Star Ratings.
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 Director of Quality Improvement leads enterprise-wide quality strategy initiatives, including NCQA accreditation, HEDIS performance, and risk adjustment processes. They also oversee health equity programs, provider satisfaction surveys, and collaborate with internal and external stakeholders to improve healthcare outcomes.
The Senior Director leads analytic service delivery by aligning strategic objectives with tool development and managing cross-functional analytic teams. This role partners with executive leadership to translate complex healthcare data into actionable business insights and ensures the realization of analytics strategy.
The analyst will interpret and analyze complex healthcare datasets to measure the impact of contract and network changes on business outcomes. They will also develop scripts, reports, and automated solutions to support network strategy and provide actionable insights to stakeholders.
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 under the guidance of a manager.
The Quality Improvement Coordinator II conducts compliance reviews, medical record audits, and utilization performance assessments for delegated entities. They also act as a liaison for clinical initiatives, investigate quality of care complaints, and develop corrective action plans to ensure organizational standards.
Lead and steward the paid media strategy for assigned products to drive cohesive marketing activities at local, state, and national levels. Manage annual digital marketing budgets, collaborate with cross-functional teams, and optimize campaigns to achieve business goals like awareness and member growth.
The clinician performs clinical reviews to assess the medical appropriateness of mental health and substance abuse services. They also conduct prior authorization and concurrent reviews while engaging with providers and leadership to improve care quality.
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.
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.
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.
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.
The Lead Grievance & Appeals Coordinator provides direction for daily appeals operations and monitors team output to ensure compliance with internal and NCQA standards. They also support staff through coaching, process improvement, and serving as a point of contact for members and providers.
The Program Manager will lead cross-functional projects to improve program efficiency and ensure regulatory compliance across operational and business functions. They are responsible for coordinating enterprise responses to regulatory inquiries and managing the full project lifecycle from requirements gathering to deployment.
The Care Coordinator II manages a caseload of 150-200 members, providing telephonic outreach and home visits to support infants and families during their child's first year. They coordinate care activities, maintain member records, and facilitate communication between healthcare providers and families to ensure continuity of care.
The manager will develop and implement strategic fraud, waste, and abuse activities while monitoring business processes to ensure billing and claims integrity. They will also lead teams of analysts, prepare saving reports, and present programs to state and federal personnel.
The Senior Manager will lead high-impact quality improvement initiatives across claims operations by leveraging data, technology, and automation. They are responsible for overseeing NCQA accreditation, managing audit activities, and driving operational excellence through continuous improvement strategies.
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 LTSS Service Care Manager develops and coordinates holistic care management activities to ensure quality, cost-effective healthcare outcomes for long-term care members. They also conduct assessments, create personalized service plans, and facilitate access to community resources and healthcare providers.
The Specialty Court Liaison collaborates with judicial and system partners to implement effective processes and monitor service delivery for justice-involved members. They are responsible for identifying service gaps, developing program initiatives, and ensuring compliance with contract expectations.
Coordinate and negotiate hospital, physician, and ancillary service agreements while ensuring compliance with corporate and state guidelines. Monitor provider performance standards and facilitate contract configuration to ensure accurate claims adjudication.
Develops, assesses, 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 monitors member progress toward health goals.
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 Vice President will lead the enterprise prospective risk adjustment strategy, operations, and governance across Medicare, Marketplace, and Medicaid lines of business. They are responsible for overseeing vendor performance, provider engagement initiatives, and clinical documentation improvement programs to ensure operational excellence.
The specialist will plan, develop, and track process improvement projects related to clinical outcomes and serve as a subject matter expert for clinical health initiatives. They will also review clinical member materials and collaborate with the analytics team to evaluate quality measures and reporting.
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.
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 Senior Compliance Analyst will assist in maintaining the corporate compliance program by performing regulatory interpretation, reporting, and auditing. They will also lead special projects, manage ethics initiatives, and serve as a liaison for regulatory agencies and internal stakeholders.
The Vice President of Retrospective Programs leads the enterprise retrospective risk adjustment operations, overseeing chart retrieval, coding quality, and analytics strategy. This role manages vendor partnerships, ensures regulatory compliance, and drives cross-functional alignment to deliver accurate and sustainable program outcomes.
The Clinical Program Manager is responsible for managing and tracking clinical projects that advance the health plan's strategic objectives and Triple Aim goals. They facilitate cross-functional initiatives, analyze clinical data, and develop workflows and reports to support provider partners and internal stakeholders.
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 representative will develop market penetration for Medicaid and Medicare products while building strategic relationships with community organizations and stakeholders. They are responsible for supporting member education, outreach, enrollment, and retention efforts to ensure access to healthcare services.
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.
Conduct provider medical record audits and analyze coding patterns to ensure accurate CMS payment and quality of care. Develop and deliver educational work plans for providers regarding risk adjustment guidelines and compliance.
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 monitor progress toward health goals.
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 Senior Compliance Analyst assists in maintaining the corporate compliance program by performing regulatory interpretation, reporting, and auditing. They also lead special projects and serve as a liaison for regulatory agencies and internal stakeholders.
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 strategist plans, organizes, and monitors quality-related projects to meet strategic objectives and enterprise-wide initiatives. They also analyze quality metrics, develop risk assessments, and facilitate training to improve health plan performance.
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 Clinical Review Nurse performs concurrent reviews to evaluate medical necessity, level of care, and resource consumption for Medicaid members. They also collaborate with healthcare providers and medical directors to facilitate appropriate discharge planning and ensure high-quality care delivery.
The manager will lead a team of clinical investigators to review and audit complex fraud, waste, and abuse cases. They will also collaborate with providers and stakeholders to define medical policy and ensure efficient audit processes.
The Director of Care Management oversees the care management team to develop and implement strategies that improve healthcare outcomes and member experience. They are responsible for departmental operations, budget management, and ensuring compliance with regulatory and NCQA standards.
Facilitate medical necessity grievances, appeals, and denials while reviewing clinical data to ensure compliance with company policies and NCQA guidelines. Identify quality care concerns, prepare case reviews for the Medical Director, and assist in system improvements for member care.
Perform comprehensive audits of provider claims to identify mis-payments and determine root causes for errors. Maintain audit criteria, update pricing tools, and provide written documentation regarding audit observations.
The Senior Clinical Review Nurse evaluates complex prior authorization requests to determine medical necessity and appropriate levels of care. They collaborate with healthcare providers and interdepartmental teams to ensure quality, cost-effective care and compliance with regulatory standards.
Lead a team in executing end-to-end Medicare, Duals, and Marketplace audit activities while managing reporting and corrective action monitoring. Drive process improvements and oversee operational audits across multiple functional areas including claims, eligibility, and provider services.
The manager will lead teams to investigate fraud, waste, and abuse while ensuring billing and claims payment integrity. They are responsible for developing fraud plans, preparing saving reports, and presenting programs to state and federal personnel.
The Care Coordinator II performs member outreach via phone or home visits to facilitate care plans and ensure continuity of services for the foster care population. They also coordinate with healthcare providers and community partners to address member needs and maintain accurate records in compliance with regulatory standards.
Oversee and manage the quality improvement program, specifically leading the state HEDIS audit and regulatory submission portfolio. Serve as a key escalation point for health plans and auditors while ensuring compliance with state and federal requirements.
The Community Relations Specialist leads activities to achieve membership and enrollment goals through marketing projects, community events, and provider networking. They also act as a department liaison for market materials and collaborate with the sales team to execute market strategies.
The Community Relations Specialist leads activities to achieve membership and enrollment goals through marketing projects, community events, and provider networking. They also develop business relationships, manage market materials, and coordinate with the sales team to execute field marketing strategies.
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 manager will lead teams to investigate fraud, waste, and abuse while ensuring compliance with state and federal billing requirements. They are responsible for developing fraud plans, preparing saving reports, and managing contractual obligations for vended programs.
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 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.
The LTSS Service Care Manager develops and coordinates holistic care management activities to ensure quality, cost-effective healthcare outcomes for long-term care members. They also conduct site visits, maintain documentation, and educate members and their families on available services and benefits.
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 Accreditation Specialist develops and maintains accreditation readiness schedules while coordinating performance improvement projects to enhance clinical quality. They also act as a liaison for delegation oversight and conduct training programs to support NCQA and HEDIS activities.
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 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.
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.
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.
The coordinator performs administrative care management activities, including member outreach, scheduling services, and resolving inquiries from members and providers. They also maintain non-clinical member records in accordance with state and regulatory guidelines to ensure high-quality service.
The Senior Care Manager assesses, plans, and implements complex care management activities to ensure quality, cost-effective healthcare outcomes for Medicaid members. They also collaborate with providers and caregivers to develop personalized care plans and provide guidance to clinical new hires during the onboarding process.
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.
Directs the care management team to develop and assess high-quality, cost-effective healthcare outcomes while overseeing departmental operations and performance. Sets strategic objectives, manages talent, and ensures compliance with regulatory and NCQA standards.
The supervisor oversees care coordination activities and team members to ensure the delivery of appropriate services and continuity of care. They are responsible for monitoring documentation, managing caseloads, and providing coaching to ensure compliance with regulatory 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 Sales Representative will develop market penetration for Medicare products by conducting community outreach, home visits, and educational events. They are responsible for identifying prospective enrollees, facilitating the enrollment process, and maintaining compliance with regulatory marketing guidelines.
Oversees the care management of high-acuity, long-term care members to ensure high-quality, cost-effective healthcare outcomes. Manages and coordinates care management teams, including monitoring caseloads, ensuring regulatory compliance, and driving process improvements.
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 Care Coordinator II supports care management activities by performing member outreach via phone or home visits to discuss care plans and ensure continuity of services. They coordinate care activities with healthcare providers and community partners while documenting member needs and maintaining records in compliance with regulatory standards.
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 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 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 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.
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.
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.
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.
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 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.
The consultant is responsible for clinical content in data collection, audit activities, and account implementations to ensure high-quality service team performance. They lead data analysis projects, interpret clinical data for regulatory compliance, and recommend operational process improvements.
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 Sales Representative will develop market penetration for Medicare products by conducting community outreach, home visits, and personalized appointments. They are responsible for facilitating enrollments, educating individuals on health benefits, and ensuring compliance with regulatory marketing guidelines.
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 manager oversees Medicare or Broker Field Sales teams to achieve regional sales goals and drive enrollment growth. They are responsible for recruiting, training, and managing relationships with brokers, providers, and community partners while ensuring compliance with company and government regulations.
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 role serves as a subject matter expert responsible for executing the Medicare Compliance Advisory program in alignment with CMS requirements and federal regulations. Responsibilities include conducting regulatory research, providing advisory support to leadership, managing compliance issues, and supporting audit readiness activities.
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.
Develops, assesses, 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 monitors progress toward health goals.
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.
The Sales Representative will develop market penetration for Medicare products by conducting community outreach, health screenings, and personalized enrollment appointments. They are responsible for educating prospective members on benefits, managing enrollment documentation, and maintaining compliance with regulatory marketing guidelines.
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 supports clinical policy by ensuring accurate coding of coverage and claims edit guidelines while maintaining authorization management tools. They also conduct regulatory research and collaborate across departments to support medical management initiatives and strategic business objectives.
The manager oversees the grievance and appeals department, ensuring all processes comply with contractual, legal, and regulatory requirements. They also manage staff, monitor trends, and serve as the primary point of contact for state and federal government entities.
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.
Develops and facilitates complex care management activities for members with mental and behavioral health needs, including personalized care plans and education. Collaborates with providers, families, and community resources to ensure accessible, high-quality, and cost-effective healthcare outcomes.
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 Quality Practice Advisor establishes and maintains relationships with physician practices to educate them on NCQA HEDIS measures, risk adjustment, and documentation standards. They also analyze provider performance data to identify improvement opportunities and support the implementation of quality interventions.
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 Psychologist Reviewer authorizes, directs, and monitors behavioral health care while conducting peer reviews for outpatient services and psychological testing. They also provide clinical education to network practitioners and collaborate with medical directors to ensure evidence-based care.
Leads and develops a team of Provider Relations staff to manage regional network performance and implement transformation strategies. Monitors provider performance, ensures regulatory compliance, and drives quality improvement initiatives like HEDIS and STARS.
Design, implement, and maintain training resources while leading stakeholder meetings to align learning strategies with business requirements. Develop assessments, oversee training support sites, and research industry trends to ensure curriculum effectiveness.
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 Operations Auditor is responsible for auditing systems entry, performance metrics, and work processes to ensure data integrity and regulatory compliance. They will also execute risk-based audits, compile findings for management, and develop corrective actions to improve operational efficiency.
Provides strategic leadership for teams performing complex clinical and coding reviews to ensure regulatory compliance and payment integrity. Analyzes performance trends and standardizes processes to drive operational efficiency and program growth.
The Senior Actuarial Analyst supports risk adjustment programs by ensuring accurate capture, validation, and reporting of member health conditions. They also apply statistical and financial principles to calculate outcomes, develop premium rates, and assess liabilities.
The Clinician Specialist provides clinical and operational support for utilization and case management, including the development and monitoring of clinical guidelines and policies. They also oversee the creation of member and provider communications while ensuring regulatory compliance and operational efficiency.
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.
The manager will oversee financial planning, forecasting, and reporting while leading a team of financial analysts to drive operational accountability. They are responsible for analyzing complex financial data and partnering with business leaders to support healthcare service effectiveness.
The Medical Director assists in coordinating medical management, quality improvement, and credentialing functions while providing clinical leadership for utilization management and cost-containment activities. They also collaborate with clinical teams and providers to optimize patient outcomes and ensure compliance with regulatory and accreditation standards.
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.
Direct and oversee all training activities, including assessment, material development, and facilitation across the business unit. Collaborate with management and HR to identify organizational gaps, implement training initiatives, and evaluate program effectiveness and ROI.
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 manager will develop and implement strategic fraud, waste, and abuse activities while monitoring business processes to ensure billing and claims integrity. They will also lead an investigation team, prepare saving reports, and participate in interdepartmental meetings.
Develops and coordinates personalized care plans to improve healthcare outcomes for members. Provides psychosocial support and facilitates access to community resources such as housing, education, and foster care services.
The Lead SIU Investigator acts as a subject matter expert, providing guidance to staff while managing complex investigations into fraud, waste, and abuse. They are responsible for identifying trends, developing investigative plans, and ensuring compliance with federal and state regulations.
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.
Manage provider data management projects, policies, and directories to support successful claims adjudication and operational efficiency. Supervise staff performance and collaborate with internal departments and IT to implement business application changes.
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.
Authorize and monitor behavioral health care for members based on clinical information and medical necessity criteria. Conduct peer reviews and collaborate with network practitioners and medical directors to ensure high-quality care for individuals with Autism.
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.
The Pharmacy Quality Performance Manager partners with health plans and provider groups to drive and accelerate pharmacy quality measures across various lines of business. They provide clinical expertise, develop performance reviews, and coordinate enterprise-wide quality initiatives.
Lead the development of financial models and risk assessments to optimize Value-Based Care strategies and vendor arrangements. Collaborate with internal partners to ensure health plan operations are analytically sound and financially viable.
Conduct pricing and risk assessments to estimate financial outcomes and manage actuarial needs for specific health plans. Support Value-Based Care strategies by developing financial models and analyzing healthcare datasets to track performance.
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.
The role partners with Health Plans and Shared Services to translate privacy, security, and AI requirements from contracts and laws into actionable enterprise controls. It involves managing compliance evidence, driving early engagement with risk management, and ensuring audit readiness across the organization.
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.
The role involves designing and implementing actuarial methodologies to measure the financial impact of Value-Based Care and Quality and Affordability Initiatives. The Associate Actuary will serve as a strategic liaison, translating complex financial data into narratives for executive stakeholders.
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.
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.
Supervises the clinical review team to ensure appropriate care through prior authorization, concurrent, and retrospective reviews. Monitors UM resources for compliance and quality while collaborating with senior management to improve processes and policies.
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.
Analyze extensive healthcare datasets to identify cost-saving opportunities and improve clinical outcomes for members. Collaborate with business stakeholders to develop reporting tools and communicate data-driven insights to optimize medical spend.
Accountable for day-to-day operations, profitability, and growth of the business unit. Responsible for developing strategic plans, managing provider networks, and ensuring compliance with state and federal regulatory agencies.
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.
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.
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.
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.
