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At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.Position SummaryUtilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours.<ul> <li>Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.</li> <li> Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care</li> <li>Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs</li> <li>Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization</li> <li>Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.</li> <li>Typical office working environment with productivity and quality expectations.</li> <li>Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.</li> <li>Sedentary work involving periods of sitting, talking, listening.</li> <li>Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.</li> <li>Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.</li> <li>Effective communication skills, both verbal and written</li> </ul> Required Qualifications- 2+ years of experience as a Registered Nurse in adult acute care/critical care setting - Must have active current and unrestricted RN licensure in state of residence- Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours Preferred Qualifications- 2+ years of clinical experience required in med surg or specialty area - Managed Care experience preferred, especially Utilization Management- Preference for those residing in zones EducationAssociates Degree requiredBSN preferredAnticipated Weekly Hours40Time TypeFull timePay RangeThe typical pay range for this role is:$32.01 - $68.55This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.Great benefits for great peopleWe take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:<ul> <li>Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.</li> <li>No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.</li> <li>Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.</li> </ul>For more information, visit <a href="https://jobs.cvshealth.com/us/en/benefits" target="_blank">https://jobs.cvshealth.com/us/en/benefits</a>We anticipate the application window for this opening will close on: 04/30/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

CVSHealth

Utilization Management Nurse Consultant

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. Position Purpose: The Network Performance Advisor (NPA) serves as a key point of contact and liaison between assigned strategic providers and various departments within WellCare, including Quality, Operations, Finance, Health Services and other shared services departments. The NPA is responsible for ensuring white glove service to the providers. The NPA will develop and execute the strategy for their assigned providers, including building strong working relationship; building trust, maintaining high provider satisfaction and helping providers improve their performance. The Network Performance Advisor will be responsible for executing Network Transformation Strategies in order to manage overall network performance. The NPA will be responsible for the provider's overall performance. <ul><li>Owns and manages the relationship and performance of key provider groups.</li></ul> <ul><li>Influences provider behaviors to drive improvements in provider &amp; member satisfaction, optimizing member outcomes and maximizing shared savings.</li></ul> <ul><li>Drives improvement of provider performance by analyzing, interpreting and communicating financial, utilization and quality metrics.</li></ul> <ul><li>Establishes and leads cross-functional communication and collaboration with internal departments to support provider performance and resolve barriers and challenges.</li></ul> <ul><li>Serves as a primary liaison to providers on claim related content working with other departments for resolution.</li></ul> <ul><li>Responsible for understanding the differences between Risk and Value-Based contracting and driving improved provider performance.</li></ul> <ul><li>Plans, prepares, and executes effective group meetings/discussions with proper objectives and outcome.</li></ul> <ul><li>Responsible for understanding unique contract, quality, network requirements of Medicaid and Medicare.</li></ul> <ul><li>Responsible for understanding HEDIS and STARS measures and partner the Quality team to drive improved provider performance.</li></ul> <ul> <li>Special projects as assigned or directed.</li> <li>Performs other duties as assigned</li> </ul> <ul><li>Complies with all policies and standards</li></ul>Education/Experience: Required A Bachelor's Degree in Health Care, Business, Finance or any other field: Required or equivalent work experience in Network Management/Network Development, Provider Relations, Risk and /or Value Base Contracting: Candidate Experience: Required 5+ years of experience in Network Management/Network Development, Provider Relations, Risk and/or Value Base Contracting, managed care organization: Required 2+ years of experience in Account Management or management experiencePay Range: $55,100.00 - $99,000.00 per yearCentene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.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. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

Oklahoma Complete Health

Network Performance Advisor

Authorization Specialist II

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. This position is a fully remote position supporting Sunshine Health Plan. Applicants must reside in Florida as well as have Florida Licensure as one of the three following:LMFTLMHCLPCPosition Purpose: Develops, assesses, and facilitates complex care management activities for primarily mental and behavioral health needs members to provide high quality, cost-effective healthcare outcomes including personalized care plans and education for members and their families related to mental health and substance use disorder.<ul> <li>Evaluates the needs of the member via phone or in-home visits related to the resources available, and recommends and/or facilitates the care plan/service plan for the best outcome, which may include behavioral health and social determinant needs</li> <li>May perform telephonic, digital, home and/or other site visits outreach to assess member needs and collaborate with resources</li> <li>Develops ongoing care plans for members with high level acuity and works to identify providers, specialists, and community resources needed for care including mental health and substance use disorders</li> <li>Coordinates as appropriate between the member and/or family/caregivers, community resources, and the care provider team to ensure identified services are accessible to members</li> <li>Monitors care plans/service plans and/or member status and outcomes for changes in treatment side effects, complications and clinical symptoms and provides recommendations to care plan/service plan based on identified member needs</li> <li>Facilitates care coordination and collaborates with appropriate providers or specialists to ensure member has timely access to needed care or services</li> <li>Collects, documents, and maintains member information and care management activities to ensure compliance with current state, federal, and third-party payer regulators</li> <li>Provides education to members and their families on procedures, healthcare provider instructions, treatment options, referrals, and healthcare benefits, which may include behavioral health and social determinant needs</li> <li>Provides feedback to leadership on opportunities to improve and enhance care and quality delivery for members in a cost-effective manner</li> <li>Performs other duties as assigned</li> <li>Complies with all policies and standards</li> </ul>Education/Experience: Requires a Master's degree in Behavioral Health or Social Work or a Degree from an Accredited School of Nursing and 2 – 4 years of related experience. License/Certification:<ul><li>Licensed Behavioral Health Professional or RN based on state contract requirements e.g., LCSW, LMSW, LMFT, LMHC, LPC and RN with BH experience required</li></ul>Pay Range: $55,100.00 - $99,000.00 per yearCentene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.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. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

Behavioral Health Care Manager

<h3> Position Summary </h3> Position Summary As a Sr. GenAI Engineer, you will actively engage in your engineering craft, taking a hands-on approach to multiple high-visibility projects. Your expertise will be pivotal in delivering solutions that delight customers and users, while also driving tangible value for Deloitte's business investments. You will leverage your extensive GenAI &amp; engineering craftsmanship and advanced proficiency across multiple programming languages and modern frameworks, consistently demonstrating your exemplary track record in delivering high-quality, outcome-focused solutions. Recruiting for this role ends on 4.1.25 Work you’ll do <ul> <li> Outcome-Driven Accountability: Embrace and drive a culture of accountability for customer and business outcomes. Develop engineering solutions that solve complex problems with valuable outcomes, ensuring high-quality, lean designs and implementations.</li> <li> Technical Leadership and Advocacy: Serve as the technical advocate for products, ensuring code integrity, feasibility, and alignment with business and customer goals. Lead requirement analysis, contributing to low-level architecture and component design, development, unit testing, integrations, and support.</li> <li> Engineering Craftsmanship: Maintain accountability for the integrity of code design, implementation, quality, data, and ongoing maintenance and operations. Stay hands-on, self-driven, and continuously learn new approaches, languages, and frameworks with significant focus on infusing AI/ML/GenAI where possible/appropriate. Create technical specifications, and write high-quality, supportable, scalable code and review code of other engineers, mentoring them, to ensure all quality KPIs are met or exceeded. Demonstrate collaborative skills to work effectively with diverse teams.</li> <li> Customer-Centric Engineering: Develop lean engineering solutions through rapid, inexpensive experimentation to solve customer needs. Engage with customers and product teams before, during, and after delivery to ensure the right solution is delivered at the right time.</li> <li> Incremental and Iterative Delivery: Adopt a mindset that favors action and evidence over extensive planning. Utilize a leaning-forward approach to navigate complexity and uncertainty, delivering lean, supportable, and maintainable solutions.</li> <li> Cross-Functional Collaboration and Integration: Work collaboratively with empowered, cross-functional teams including product management, experience, and delivery. Integrate diverse perspectives to make well-informed decisions that balance feasibility, viability, usability, and value. Foster a collaborative environment that enhances team synergy and innovation.</li> <li> Advanced Technical Proficiency: Possess deep expertise in modern software engineering practices and principles, including AI/ML/GenAI, Agile methodologies and DevSecOps to deliver daily product deployments using full automation from code check-in to production with all quality checks through SDLC lifecycle. Strive to be a role model, leveraging these techniques to optimize solutioning and product delivery. Demonstrate strong understanding of the full lifecycle product development, focusing on continuous improvement and learning.</li> <li> Domain Expertise: Quickly acquire domain-specific knowledge relevant to the business or product. Translate business/user needs, architectures, and UX/UI designs into technical specifications and code. Be a valuable, flexible, and dedicated team member, supportive of teammates, and focused on quality and tech debt payoff.</li> <li> Effective Communication and Influence: Capable of articulating complex technical concepts clearly and compellingly. Inspire and influence teammates and product teams through well-structured arguments and trade-offs supported by evidence. Create coherent narratives that align technical solutions with business objectives.</li> <li> Engagement and Collaborative Co-Creation: Engage and collaborate with product engineering teams at all organizational levels, including customers as needed. Build and maintain constructive relationships, fostering a culture of co-creation and shared momentum towards achieving product goals. Align diverse perspectives and drive consensus to create feasible solutions.</li> </ul> The successful candidate will have and/or be able to: The ideal candidate will be a dependable team player and mentor, collaborating with cross-functional teams to design, develop, and deploy advanced software solutions. <ul> <li>Understanding and experience in managing big data of various forms to generate insights and create intelligence.</li> <li>Understanding of methodologies &amp; tools like, XP, Lean, SAFe, DevSecOps, SRE, ADO, GitHub, SonarQube, etc. to deliver high quality products rapidly.</li> <li>Excellent interpersonal and organizational skills, with the ability to handle diverse situations, complex projects, and changing priorities, behaving with passion, empathy, and care.</li> </ul> The Team US Deloitte Technology Product Engineering has modernized software and product delivery, creating a scalable, cost-effective model that focuses on value/outcomes that leverages a progressive and responsive talent structure. As Deloitte’s primary internal development team, Product Engineering delivers innovative digital solutions to businesses, service lines, and internal operations with proven bottom-line results and outcomes. It helps power Deloitte’s success. It is the engine that drives Deloitte, serving many of the world’s largest, most respected companies. We develop and deploy cutting-edge internal and go-to-market solutions that help Deloitte operate effectively and lead in the market. Our reputation is built on a tradition of delivering with excellence. Qualifications Required: <ul> <li>Bachelor's degree in computer science, software engineering, or related field.</li> <li>6+ years of engineering experience focused in AI/ML</li> <li>2+ years of recent experience in GenAI utilizing technologies such as: OpenAI, Claude, Gemini, LangChain, Agents, Vector databases and approaches like Prompt Engineering, fine-tuning, etc.</li> <li>Limited immigration sponsorship may be available</li> </ul> Preferred: <ul> <li>8+ years of engineering experience focused in AI/ML</li> <li>Prior experience in Python, R, TensorFlow, PyTorch, Keras, Julia, ML libraries, NLP.</li> <li>Prior experience with Angular, React, NodeJS, Python, Streamlit, C#, .NET Core, Golang, SQL/NoSQL.</li> <li>Prior experience with experience with cloud-native engineering, using FaaS/PaaS/micro-services on cloud hyper-scalers like Azure, AWS, and GCP.</li> <li>Prior experience and familiarity with XP, Lean, SAFe, DevSecOps, SRE, ADO, GitHub, SonarQube.</li> <li>Advanced degree (e.g., MS) in computer science, software engineering, or related field.</li> </ul> The wage range for this role takes into account the wide range of factors that are considered in making compensation decisions including but not limited to skill sets; experience and training; licensure and certifications; and other business and organizational needs. The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the position may be filled. At Deloitte, it is not typical for an individual to be hired at or near the top of the range for their role and compensation decisions are dependent on the facts and circumstances of each case. A reasonable estimate of the current range is $102,500 to $ 210,600. You may also be eligible to participate in a discretionary annual incentive program, subject to the rules governing the program, whereby an award, if any, depends on various factors, including, without limitation, individual and organizational performance. Information for applicants with a need for accommodation: Hyperlink: <a href="https://www2.deloitte.com/us/en/pages/careers/articles/join-deloitte-assistance-for-disabled-applicants.html" target="_blank">https://www2.deloitte.com/us/en/pages/careers/articles/join-deloitte-assistance-for-disabled-applicants.html</a> EA_ITS_ExpHire Recruiting tips From developing a stand out resume to putting your best foot forward in the interview, we want you to feel prepared and confident as you explore opportunities at Deloitte. <a href="https://www2.deloitte.com/us/en/pages/careers/topics/recruiting-tips.html" target="_blank">Check out recruiting tips from Deloitte recruiters.</a> Benefits At Deloitte, we know that great people make a great organization. We value our people and offer employees a broad range of benefits. <a href="https://www2.deloitte.com/us/en/pages/careers/articles/life-at-deloitte-benefits-and-rewards.html" target="_blank">Learn more about what working at Deloitte can mean for you.</a> Our people and culture Our inclusive culture empowers our people to be who they are, contribute their unique perspectives, and make a difference individually and collectively. It enables us to leverage different ideas and perspectives, and bring more creativity and innovation to help solve our client most complex challenges. This makes Deloitte one of the most rewarding places to work. Our purpose Deloitte’s purpose is to make an impact that matters for our clients, our people, and in our communities. We are creating trust and confidence in a more equitable society. At Deloitte, purpose is synonymous with how we work every day. It defines who we are. We are focusing our collective efforts to advance sustainability, equity, and trust that come to life through our core commitments. <a href="https://www2.deloitte.com/us/en/pages/about-deloitte/articles/purpose-at-deloitte-us.html" target="_blank">Learn more about Deloitte's purpose, commitments, and impact.</a> Professional development From entry-level employees to senior leaders, we believe there’s always room to learn. We offer opportunities to build new skills, take on leadership opportunities and connect and grow through mentorship. From on-the-job learning experiences to formal development programs, our professionals have a variety of opportunities to continue to grow throughout their career.

Deloitte

Manager, GenAI Engineering

Centene is transforming the health of our communities one person at a time. As an Executive on our team, you could be the one who changes everything for our 28 million members. Position Purpose:Expand the provider network development and value based contracting activities. Assist with value based contracting provider network strategy, including provider contract negotiation, development of new value-based models, drive provider performance related to quality and reduction of avoidable healthcare costs, assist with preparation for provider performance meetings, and support decision makers with analysis related to historical and projected provider performance.Below relates to value based efforts only:<ul> <li>Develop relationships in multiple markets and implement strategies with key providers, provider associations and provider stakeholders</li> <li>Lead key provider negotiations with Hospitals, Physicians, Ancillaries, and Community Health Centers</li> <li>Develop and implement network development strategy plans with key providers in multiple markets</li> <li>Oversee the development of provider networks across expansion markets</li> <li>Manage budgeting and forecasting initiatives for stakeholder/network strategies, product lines, networks costs, and/or provider contracts</li> <li>Develop, coordinate and managed provider advisory boards, committee’s and governance and maintain relationships with key provider leadership</li> <li>Assist and advise on key provider relations and strategies</li> <li>Evaluating opportunities to expand or change the network to meet company goals</li> </ul>Education/Experience:Bachelor's degree in Business, Management, Healthcare Administration, or related field. MBA preferred.10+ years of healthcare administration, network development, or provider/payor contracting experience in a healthcare or managed care environment.Provider network development and strategy, provider contract negotiations, leading network development staff, unit cost and network strategy budgeting.Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.Pay Range: $182,100.00 - $345,600.00 per yearCentene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.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. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

Staff Vice President, Value-Based Contracting Network Strategy & Development

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. Position Purpose: Ensure regulatory compliance with federal and state legal and regulatory requirements as it relates to Medicare compliance and HPMS/CMS regulations.<ul> <li>Oversee and monitor various of cross-functional projects implemented by management.</li> <li>Develop strategic relationships to assist with the development of public policy concerning federal managed care regulations and initiatives.</li> <li>Represent senior management at various committees, meetings, and seminars.</li> <li>Communicate with CMS ensure timely completion of CMS requirements and expectations.</li> <li>Ensure all Medicare and Medicaid product and services are being tested for compliance with program regulations, insurance regulations, and regulatory requirements for business entities.</li> <li>Maintain and track laws and regulations, contract documentations, amendments, and carious compliance measures.</li> <li>Develop policies, procedures, and process to comply with federal program regulations, and any applicable state regulations.</li> <li>Work with Operational Departments to ensure that policies, procedures, and processes are developed and modified to comply with state regulatory standards. Provide guidance to various departments with respect to regulatory and contract language.</li> <li>Oversee, administer, and implement various aspects of the Medicare Compliance program.</li> <li>Provide guidance to various departments regarding compliance issues and implementation of new compliance requirements with respect to regulatory and contract language.</li> <li>Identify, evaluate, and analyze the impact of CMS and Medicare regulatory issues and advise management concerning impact.</li> <li>Report all Medicare and MMP risks in accordance with the risk reporting policies.</li> <li>Provide required Ethics, Compliance, Risk Management, FWA, privacy, and security training for existing and new employees and as required non-employees such as contracted temporary staff, and FDR’s as needed.</li> <li>Partner with various departments to ensure that state and/or federal regulatory requirements are communicated and met.</li> <li>Performs other duties as assigned.</li> <li>Complies with all policies and standards.</li> </ul>Education/Experience:<ul> <li>Bachelor’s degree Business Administration, Healthcare Administration, related field or equivalent experience. Master's Degree Business Administration, Healthcare Administration, or related field preferred. Pre-Law Degree or Juris Doctor preferred.</li> <li>7+ years Compliance, preferably in healthcare environment, required.</li> <li>5+ years Medicare and/or Managed Care, required.</li> <li>1+ years Overseeing implementation of contract requirements, required.</li> <li>1+ years Interaction and communication with federal and state regulatory agencies, preferred.</li> <li>1+ years Medicare, CMS regulations and software application tools, preferred.</li> </ul>Pay Range: $145,100.00 - $268,800.00 per yearCentene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.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. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

Senior Director, Compliance Advisory (Medicare)

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. Applicants for this job have the flexibility to work remote from home anywhere in the Continental United States.Position Purpose: Perform internal audits, including the execution of strategic, operational, IT, and compliance risk-based audits for the company<ul> <li>Design, perform, and manage risk-based audits, evaluating controls and processes for scalability, effectiveness, efficiency, and risk mitigation strategies</li> <li>Perform audit planning, fieldwork, and wrap-up of engagements, including development and refinement of work programs</li> <li>Draft audit reports summarizing key findings and recommendations and consolidation of metrics and graphing</li> <li>Develop and communicate audit observations, recommendations, process improvement opportunities and best practices and obtain management responses</li> <li>Monitor and report on the status and findings of audits</li> <li>Serve as contact for corporate and external auditors regarding auditing, fraud matters, and projects</li> <li>Work with external professionals to complete audits/projects</li> </ul>Education/Experience:<ul> <li>Bachelor’s degree in Business, Accounting, Finance, Healthcare, related field or equivalent experience.</li> <li>2+ years of public accounting, internal audit, or related operational auditing or compliance experience required.</li> <li>Knowledge of Generally Accepted Accounting Principles required.</li> <li>Health Care industry experience preferred.</li> </ul> License/Certificates: CPA, CIA and/or CISA preferred.Pay Range: $55,100.00 - $99,000.00 per yearCentene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.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. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

Compliance Internal Auditor

Centene is transforming the health of our communities one person at a time. As an Executive on our team, you could be the one who changes everything for our 28 million members. Position Purpose: Responsible for developing and managing the provider network strategy for Centene Corporation. Lead all aspects of provider network strategy including, but not limited to reimbursement strategy, contracting strategy, unit cost management, claims configuration and network operations. <ul> <li>Oversee network development staff and external consultants in the development of provider networks across expansion markets</li> <li>Lead health plans in periodic analyses of their provider networks from a cost, coverage, and growth perspective</li> <li>Provide leadership in evaluating opportunities to expand or change the network to meet Company goals</li> <li>Manage budgeting and forecasting initiatives for product lines to networks costs and provider contracts</li> <li>Oversee analysis of claim trend data and/or market information to derive conclusions to support contract negotiations</li> <li>Lead initiatives to ensure periodic review of provider contracting rates to ensure strategic focus is on target with overall Company strategy</li> <li>Lead development of fee schedules and rates for new and existing markets consistent with budget and premium revenue assumptions (includes physicians, hospitals and ancillaries). Support market expansion and M&amp;A activities by leading provider contract analysis related to due diligence</li> <li>Assist health plan CEOs, network development, legal and finance teams in key provider contract negotiations and strategy</li> <li>Work collaboratively with Business Development on new market and new product development initiatives</li> <li>Ability to travel</li> </ul>Education/Experience: Bachelor's degree in Business Administration, Healthcare Administration or related field. MBA or MHA degree preferred. 10+ years of experience in managed care network development. 3+ years of experience in government programs. Previous experience managing staff, including hiring, training, managing workload and performance. License/Certification: Valid driver's license.Pay Range: $231,900.00 - $440,500.00 per yearCentene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.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. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

Vice President, Marketplace Network Strategy & Management

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. Applicants for this role will have the flexibility to work remotely anywhere in the Continental United Sates.Position Purpose: Provides strategic leadership and management of department overseeing compliance with regulations and laws related to Marketplace line of business, which includes implementation of elements of an effective compliance program related to specific operational areas. Oversees the development of risk assessments and oversight and monitoring work plans pertaining to those areas. Partners with business areas to ensure implement effective prevention, detection and correction of compliance issues.<ul> <li>Establish a process for overseeing compliance with regulations and laws related to Marketplace requirements</li> <li>Provides guidance to various business departments regarding compliance issues and implementation of new compliance requirements with respect to regulatory and contractual language</li> <li>Conducts compliance reviews and manages team that conducts compliance reviews, assisting with identification of issues and collaborating with Corrections team for remediation of issues</li> <li>Performs risk assessments and report emerging trends, deficiencies and variances, report findings to other departments and teams as appropriate</li> <li>Oversees team responsible for monitoring against regulatory requirements; ensures sufficient monitoring activities to assist with prevention and proactive identification of compliance concerns</li> <li>Develops and monitors metrics and other oversight tools that indicate business area compliance</li> <li>Provides compliance guidance, direction and compliance risk assessment to assigned business partners</li> <li>Manages and develops direct reports who include other management or supervisory personnel and/or exempt individual contributors</li> <li>Plans and collaborates with other teams and leaders on complex projects/programs necessitating the origination and application of new and unique approaches</li> <li>Sets operational priorities including the development and maintenance of effective oversight activities and prioritization of work</li> <li>Responsible for Board and Executive reporting related to responsibilities of the team and compliance of business operations for which you oversee</li> <li>Educates, encourages, and assists those within the company to maintain integrity through correction of identified non-compliance in order to meet the requirements of Government-sponsored health care programs</li> <li>Participates in mock and actual CMS and other regulatory audits and coordinates with Internal Audit, Regulatory Compliance and/or Market based Regulatory Affairs on responses to agency inquiries and oversees the internal and external processes required to ensure the Company maintains a consistent state of Audit readiness</li> <li>Maintains a current working knowledge of various laws, regulations, and industry guidance that impacts the health industry generally, and government programs in the health sector specifically, including fraud and abuse and anti-kickback statutes, OIG and government health plan guidelines and state marketing compliance laws, prompt pay, provider adequacy and other laws</li> <li>Makes decisions on complex issues regarding technical approach for project components and is able to work without significant direction</li> <li>Performs other duties as assigned</li> <li>Complies with all policies and standards</li> </ul>Education/Experience:<ul> <li>Bachelor's Degree Business Administration, Public Policy, Public Health, Health Administration or related field; or equivalent experience required: CPA, CISA, JD, MHA, MBA, MIS or equivalent experience preferred</li> <li>7+ years Compliance for a managed care or health insurance company or equivalent experience required</li> <li>4+ years Management experience preferred</li> </ul>Licenses/Certifications:<ul><li>HCCA certification (CHC) or equivalent preferred</li></ul>Pay Range: $116,100.00 - $214,700.00 per yearCentene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.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. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

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