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Responsible for analytic data needs of the business unit. Handle complex data projects and acts as a lead for other Data Analysts. Provide advanced analytical support for business operations in all or some of the following areas claims, provider data, member data, clinical data, HEDIS, pharmacy, external reporting Extract, load, model, and reconcile large amounts of data across multiple system pla
Posted 1 day ago
Perform various analysis and interpretation to link business needs and objectives for assigned function Support business initiatives through data analysis, identification of implementation barriers and user acceptance testing of new systems Identify and analyze user requirements, procedures, and problems to improve existing processes Perform detailed analysis on assigned projects, recommend potent
Posted 1 day ago
Director, Medical Management (Complex Care Products) Director, Medical Management (Complex Care Products) (1080154) Position Purpose Provide strategic leadership and guidance in medical management and quality across all Centene's Medicare Advantage Plans. Ensure compliance with all Centers of Medicare/Medicaid Services (CMS) clinical, quality, and service requirements and ensure a centralized stru
Posted 6 days ago
Maintain accurate databases and reports to monitor network compliance with State requirements Create and maintain multiple databases, including, contract provider network, prior authorization, third party liability, provider set ups and related corrections Oversee the provider termination process including adding and changing new or existing provider records in the medical information system Sched
Posted 8 days ago
Collaborate with internal team and external client to research and resolve any disputes or discrepancies in billed amounts and/or payment transactions Prepare timely and accurate billing for external clients Document all collections efforts and transaction records Reconcile member accounts as needed Prepare bad debt write off as needed Research and process refunds as needed Maintain low volume in
Posted 8 days ago
Identify special needs members through the completion of health screens and other resources Work with community outreach/member advocates to coordinate member care Educate providers and community resources on program components and available support services Educate members with special needs to foster compliance with program and positively impact outcomes Conduct site visits as appropriate for pr
Posted 9 days ago
Assist with the contract submission process and the auditing of provider information systems (AMISYS) for consistency and best practices in Provider set up. Maintain spreadsheets and collect, track, prepare, compile, and distribute statistical data for daily and monthly reports. Maintain and report on the Health Plan(s) compliance with contract submission rules and exception requests and communica
Posted 9 days ago
Provide analytic support for network performance, unit cost trend, network profiling and evaluation, and contract modeling for current health plans, future business, and new products. Utilize applications and tools to support network performance management reporting and analytic needs. Evaluate and monitor financial performance of key provider contracts for health plans Perform financial analyses
Posted 9 days ago
Perform various analysis and interpretation to link business needs and objectives for assigned function Support business initiatives through data analysis, identification of implementation barriers and user acceptance testing of new systems Identify and analyze user requirements, procedures, and problems to improve existing processes Perform detailed analysis on assigned projects, recommend potent
Posted 9 days ago
Perform duties related to the day to day operations of the High Risk Case Management functions to include working with members identified as high risk to identify needs and goals to achieve empowerment and improved quality of life. Assess members' current functional level and, in collaboration with the member, develop and monitor the Case Management Treatment Plan, monitor quality of care; assisti
Posted 9 days ago
Compile and analyze financial information for the company. Assist in the development of integrated revenue/expense analyses, projections, reports, and presentations Analyze monthly, quarterly, and annual reports and ensures financial information has been recorded accurately Analyze trends and developments in competitive environments and presents findings to senior analyst and management Assist in
Posted 14 days ago
Concurrent Review Nurse I RN Preferred Concurrent Review Nurse I RN Preferred (1081221) Position Purpose Perform onsite review of emergent/urgent and continued stay requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations Complete medical nece
Posted 14 days ago
Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care Develop, assess and adjust, as necessary, the care plan and promote desired outcome Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosi
Posted 14 days ago
Lead and direct process improvement activities that provide more efficient and streamlined workflow. Responsible for leading and collaborating with others on National Committee for Quality Assurance (NCQA) Accreditation and/or Healthcare Effectiveness Data and Information Set (HEDIS) performance Responsible for quality improvement aspects of risk adjustment processes for all products Collaborate w
Posted 15 days ago
Coordinate and negotiate hospital, physician (IPAs, PPMs, individual providers, multi specialty groups) and ancillary service agreements that are in accordance with corporate, health plan and State guidelines. Recruit and develop provider network plan for region and set of providers Identify and initiate contact with potential providers Negotiate contracts Leads assigned negotiations (i.e., hospit
Posted 15 days ago
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