Centene Corporation

Job ID Category Information Technology Schedule Full-time Description: Position Purpose: Provide operational and technical support to ensure the ongoing stability to the server environments. Contribute to the IT infrastructure design and leading in server implementations. This role will support Centene AV Technology stack and primary focus will be Centene University. Contribute in the technical support of the Centene server environment and the applications residing on these servers. Audit system resources and take action as deemed necessary by the Senior/Lead Systems Engineer's. Prepare and document standard operating procedures and protocols. Responsible for schedule, test, and implement enhancements or new releases of the server Operating Systems. Work with senior/lead system engineers to solve complex issues. Work with senior/lead system engineers to understand and implement IT infrastructure designs and rollouts. Qualifications: Education/Experience: Bachelor's degree in Computer Science, MIS, related field or equivalent experience. 2+ years of related experience. Healthcare experience a plus. Intermediate understanding of Video Conferencing infrastructure (ex: Polycom RMX, DMA, RPAD, CCS or Cisco TMS, CUCM, VCS), presentation technology (ex. Barco ClickShare, Crestron AirMedia) and Digital Signage (ex. Cisco DMM, Qumu). Intermediate understanding of Mobile Video (Lync, Polycom RealPresence Client, Cisco Jabber) and Video Technology protocols (ex. H.323, SIP). Experience troubleshooting video, audio orweb conferencing issues along with advanced understanding of room presentation technology, digital signage and streaming and recorded video solutions. Experience supporting video conferencing deployments that require inter-operability between Cisco, Polycom, and Lync end points. Experience implementing medium scale AV projects preferred. Description: Position Purpose: Provide operational and technical support to ensure the ongoing stability to the server environments. Contribute to the IT infrastructure design and leading in server implementations. This role will support Centene AV Technology stack and primary focus will be Centene University. Contribute in the technical support of the Centene server environment and the applications residing on these servers. Audit system resources and take action as deemed necessary by the Senior/Lead Systems Engineer's. Prepare and document standard operating procedures and protocols. Responsible for schedule, test, and implement enhancements or new releases of the server Operating Systems. Work with senior/lead system engineers to solve complex issues. Work with senior/lead system engineers to understand and implement IT infrastructure designs and rollouts.

Description: Position Purpose/: Supervise the daily operations of the utilization management (UM) department Supervise the daily operations of the UM staff Ensure appropriate usage of resources in order to facilitate the UM process Ensure compliance within applicable state program guidelines Evaluate compliance policies and procedures and analyze/recommend enhancements Assist with ensuring consistent data collection from UM staff that is used to assist the company in achieving corporate goals, to improve monitoring and reporting in order to meet external requirements Identify opportunities for process improvements necessary to facilitate department functions Educate staff as necessary to ensure consistent performance and adhere to standards Assist UM Manager and Director with coordinating and facilitating system processes with providers, partners, vendors, and subcontractors as necessary Qualification: Education/Experience/: 3+ years of utilization management/quality improvement experience. Working knowledge and understanding of basic utilization management and quality improvement concepts. Previous experience as a lead in a functional area or managing cross functional teams on large scale projects. RN Preferred. For Arizona Complete Health-Behavioral Health UM Team/: Licenses/Certifications/: Licensed Clinical Social Worker (LCSW), Licensed Master Social Worker (LMSW), Licensed Marriage & Family Therapist (LMFT), Licensed Professional Counselor (LPC), Licensed Associate Marriage & Family Therapist (LAMFT), Licensed Associate Counselor (LAC), Licensed Associate Master Social Worker (LAMSW) or Registered Nurse (RN), LPN, LVNFor Sunflower Behavioral Health UM Team/: Licenses/Certifications/: Licensed Specialist Clinical Social Worker (LSCSW), Licensed Clinical Professional Counselor(LCPC), Licensed Clinical Marriage and Family therapist (LCMFT), or Licensed Registered Nurse (RN)Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Description: Position Purpose/: Supervise the daily operations of the utilization management (UM) department Supervise the daily operations of the UM staff Ensure appropriate usage of resources in order to facilitate the UM process Ensure compliance within applicable state program guidelines Evaluate compliance policies and procedures and analyze/recommend enhancements Assist with ensuring consistent data collection from UM staff that is used to assist the company in achieving corporate goals, to improve monitoring and reporting in order to meet external requirements Identify opportunities for process improvements necessary to facilitate department functions Educate staff as necessary to ensure consistent performance and adhere to standards Assist UM Manager and Director with coordinating and facilitating system processes with providers, partners, vendors, and subcontractors as necessary Qualification: Education/Experience/: 3+ years of utilization management/quality improvement experience. Working knowledge and understanding of basic utilization management and quality improvement concepts. Previous experience as a lead in a functional area or managing cross functional teams on large scale projects. RN Preferred. For Arizona Complete Health-Behavioral Health UM Team/: Licenses/Certifications/: Licensed Clinical Social Worker (LCSW), Licensed Master Social Worker (LMSW), Licensed Marriage & Family Therapist (LMFT), Licensed Professional Counselor (LPC), Licensed Associate Marriage & Family Therapist (LAMFT), Licensed Associate Counselor (LAC), Licensed Associate Master Social Worker (LAMSW) or Registered Nurse (RN), LPN, LVNFor Sunflower Behavioral Health UM Team/: Licenses/Certifications/: Licensed Specialist Clinical Social Worker (LSCSW), Licensed Clinical Professional Counselor(LCPC), Licensed Clinical Marriage and Family therapist (LCMFT), or Licensed Registered Nurse (RN)Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

HourlyPosition Purpose: Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests. + Perform telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations + Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings + Collaborate with various staff within provider networks and case management team electronically or telephonically to coordinate member care + Educate providers on utilization and medical management processes + Provide clinical knowledge and act as a clinical resource to non-clinical team staff + Enter and maintain pertinent clinical information in various medical management systems Education/Experience: Graduate from an Accredited School of Nursing. Bachelor's degree in Nursing preferred. 2+ years of clinical nursing experience. Knowledge of healthcare and managed care preferred. Licenses/Certifications: Current State LPN/LVN or RN license. For New Hampshire Healthy Families: Candidates with active nursing licenses in good standing in other states than NH, must obtain the NH equivalent within 90 days of hire. : Active driver's license in good standing preferred. _Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law._ **TITLE:** Prior Authorization Nurse I **LOCATION:** Columbus, Ohio **REQNUMBER:** **COMPANY:** Clinical & Nursing **POSITION TYPE:** Hourly

Job ID Category Clinical & Nursing Schedule Full-time Description: Position Purpose: Manage Case Management and Care Coordination services and activities for members with co occurring behavioral health and medical conditions. Manage clinical team of licensed medical and behavioral health clinicians. Manage clinical services including oversight of clinical policies and procedures and daily activities of integrated care coordination team staff. Ensure adequate staffing to conduct case management activities and effectively distribute workloads. Ensure team members receive appropriate training to serve the population and demonstrate effective engagement activities for individuals with various disabilities including chronic physical and behavioral health conditions. Ensure Integrated Clinical Services staff are trained on NCQA and HEDIS measures and processes to ensure compliance. Ensure all programs and clinical operations are in full compliance with state and federal regulations, including HIPAA. Ensure compliance with plan's emergency management policies, procedures and processes by acting as liaison with other business units. Monitor the effectiveness of existing procedures and outreach/intervention efforts in demonstrating positive outcomes for members. Ensure appropriate case planning, education and interventions are conducted for members defined to be at risk. Ensure staff coordinate exchange of information between behavioral health and medical providers in developing comprehensive care plans for at-risk members. Monitor data to address quality measures, trends or potential improvement opportunities including provider issues, service gaps and member needs. Qualifications: Education/Experience: Bachelor's degree in Behavioral Health or related field or Graduate from an Accredited School of Nursing. 3+ years case and/or utilization management experience. Thorough knowledge in assessment, diagnosis, treatment of individuals with serious mental health or substance abuse disorders, case management, mental health community resources and local health delivery systems. Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff. License/Certification: LCSW, LMFT or LPC, or a PhD, PsyD or RN license in applicable state. Independent license required. For Specialty Therapy: Bachelor's degree in the area of specialty (Speech, Occupational, or Physical) or related field. 5+ years of specialty therapy or utilization management experience. Thorough knowledge of a specialized or technical field such as case and/or utilization management, including application of basic theory. Knowledge of utilization review procedures and familiarity with educational services. License/Certification: Current license in area of specialty (Speech, Occupational, or Physical) in applicable state. For Fidelis Care only: NYS unrestricted license as Registered Nurse (RN), Foreign Medical Graduate (FMG) or Licensed Practical Nurse (LPN) Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Description: Position Purpose: Manage Case Management and Care Coordination services and activities for members with co occurring behavioral health and medical conditions. Manage clinical team of licensed medical and behavioral health clinicians. Manage clinical services including oversight of clinical policies and procedures and daily activities of integrated care coordination team staff. Ensure adequate staffing to conduct case management activities and effectively distribute workloads. Ensure team members receive appropriate training to serve the population and demonstrate effective engagement activities for individuals with various disabilities including chronic physical and behavioral health conditions. Ensure Integrated Clinical Services staff are trained on NCQA and HEDIS measures and processes to ensure compliance. Ensure all programs and clinical operations are in full compliance with state and federal regulations, including HIPAA. Ensure compliance with plan's emergency management policies, procedures and processes by acting as liaison with other business units. Monitor the effectiveness of existing procedures and outreach/intervention efforts in demonstrating positive outcomes for members. Ensure appropriate case planning, education and interventions are conducted for members defined to be at risk. Ensure staff coordinate exchange of information between behavioral health and medical providers in developing comprehensive care plans for at-risk members. Monitor data to address quality measures, trends or potential improvement opportunities including provider issues, service gaps and member needs.

Description: Position Purpose: Analyze and resolve verbal and written claims and authorization appeals from providers and pursue resolution of formal grievances from members. Gather, analyze and report verbal and written member and provider complaints, grievances and appeals Prepare response letters for member and provider complaints, grievances and appeals Maintain files on individual appeals and grievances May coordinate the Grievance and Appeals Committee Support the pay-for-performance programs, including data entry, tracking, organizing, and researching information Assist with HEDIS production functions including data entry, calls to provider's offices, and claims research. Manage large volumes of documents including copying, faxing and scanning incoming mail Qualifications: Education/Experience: High school diploma or equivalent. Associate's degree preferred. 2+ years grievance or appeals, claims or related managed care experience. Strong oral, written, and problem solving skills. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.