Qureos Mentor

Centene

<div>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:
Provide operational leadership for Centene's Corporate Risk Adjustment program operations and its subsidiaries. Oversee compliance with Risk Adjustment data integrity and validation audit process.<ul><li>
Lead enterprise-wide Risk Adjustment operations for coding and external audits, ensuring consistent execution while addressing market, product, and regulatory variation.</li><li>
Lead and develop high performing, multi-disciplinary teams through complex change, reinforcing accountability, engagement, and results.</li><li>
Drive enterprise change management through standardized processes, tools, and controls that improve scalability, quality, and compliance.</li><li>
Oversee encounter data submissions and reconciliation to ensure data completeness, accuracy, and regulatory alignment.</li><li>
Effectively communicate risk, organizational impact and progress towards achieving goals.</li><li>
Establish strong governance and oversight for Risk Adjustment compliance, including RADV and other regulatory and internal audits.</li><li>
Work with local market teams as necessary to support Enterprise Risk Adjustment programs and education</li><li>
Ensure disciplined oversight of vendor performance, holding partners accountable to quality, timeliness, and contractual expectations.</li><li>
Performs other duties as assigned.</li><li>
Complies with all policies and standards.</li></ul>
Education/Experience:<ul><li>
Bachelor&rsquo;s degree in health information management, Nursing, Healthcare Administration, Business, or related field required, advanced degree preferred.</li><li>
10+ years of progressive leadership experience in Risk Adjustment, medical coding, healthcare compliance, or related regulated healthcare operations.</li><li>
Demonstrated experience leading large teams of certified coders, auditors, and quality professionals across multiple programs or markets.</li><li>
Deep knowledge of CMS Risk Adjustment requirements, ICD 10 CM coding standards, RADV audits, and encounter data submissions.</li><li>
Proven record of establishing coding governance, quality assurance, and audit readiness programs in highly regulated environments.</li><li>
Executive level people leadership experience, including workforce development, performance management, and leading teams through change.</li><li>
Or equivalent experience acquired through accomplishments of applicable knowledge, duties, scope and skill reflective of the level of this position.</li></ul>
Pay Range: $188,900.00 - $359,800.00 per year
Centene 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, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
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</div>

Vice President, Risk Adjustment Program Operations & Data Integrity

<div>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&rsquo;ll have access to competitive benefits including a fresh perspective on workplace flexibility. 
**Applicants for this role have the flexibility to work remotely from their home anywhere within the state of Iowa**
Position Purpose: Supervises the care management team and the care coordination of behavioral health members to promote quality and efficacy of care management delivery related to mental and behavioral health needs. Supervises day-to-day escalations and care management issues related to members or providers.<ul><li>
Monitors and reviews care management required documentation to maintain compliance with federal and state regulations and contractual agreements</li><li>
Assigns caseloads to care management staff based on state requirements, care management staff experience, and member needs</li><li>
Works with senior management on escalated and complex care cases related to BH and provides guidance to junior team members to address member concerns</li><li>
Educates and provides resources for care management team on key initiatives and member outreach</li><li>
Evaluates care management team performance and provides feedback regarding performance, goals, and career milestones</li><li>
Provides coaching and guidance to care management team and providers to ensure members are receiving high quality care and information regarding service / care plan options, procedures, referrals, and healthcare benefits</li><li>
Monitors and review reports on a regular basis ensuring quality and productivity metrics are met and for case assignments, and may perform audits of staff on a regular basis</li><li>
Assists with onboarding, hiring, and training care management team members</li><li>
Performs other duties as assigned.</li><li>
Complies with all policies and standards.</li></ul>
Education/Experience: Requires a Master's degree or Graduate from an Accredited School of Nursing and 4+ years of related experience. 
 
License/Certification:<ul><li>
Licensed Clinical Behavioral Health Professional or RN based on state contract requirements e.g., LCSW, LMSW, LMFT, LMHC, and RN with BH experience required</li></ul>
Pay Range: $87,000.00 - $161,300.00 per year
Centene 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, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
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</div>

Supervisor, Care Management

<div>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&rsquo;ll have access to competitive benefits including a fresh perspective on workplace flexibility. 
Position Purpose: 
Establishes and fosters a healthy working relationship between large physician practices, IPAs and Centene. Educates providers and supports provider practice sites regarding the National Committee for Quality Assurance (NCQA) HEDIS measures and risk adjustment. Provides education for HEDIS measures, appropriate medical record documentation and appropriate coding. Assists in resolving deficiencies impacting plan compliance to meet State and Federal standards for HEDIS and documentation standards. Acts as a resource for the health plan peers on HEDIS measures, appropriate medical record documentation and appropriate coding. Supports the development and implementation of quality improvement interventions and audits in relation to plan providers.<ul><li>
Delivers, advises and educates provider practices and IPAs in appropriate HEDIS measures, medical record documentation guidelines and HEDIS ICD-9/10 CPT coding in accordance with state, federal, and NCQA requirements.</li><li>
Collects, summarizes, trends, and delivers provider quality and risk adjustment performance data to identify and strategize/coach on opportunities for provider improvement and gap closure.</li><li>
Collaborates with Provider Relations and other provider facing teams to improve provider performance in areas of Quality, Risk Adjustment and Operations (claims and encounters).</li><li>
Identifies specific practice needs where Centene can provide support.</li><li>
Develops, enhances and maintains provider clinical relationship across product lines.</li><li>
Maintains Quality KPI and maintains good standing with HEDIS Abstraction accuracy rates as per corporate standards.</li><li>
Ability to travel up to 75% of time to provider offices.</li><li>
Performs other duties as assigned.</li><li>
Complies with all policies and standards.</li></ul>
We are seeking a Manager, Quality Improvement to join our team!
The ideal candidate will bring expertise in:
Must Reside Miami-Dade or Broward County, FL 
Field Work 15% -20% (Provider Visits)
 
2 or more Years of Medical Experience
 
HEDIS
 
Medical Records
 
Excellent Communicate and Customer and Customer Service
Education/Experience: 
Bachelor's Degree or equivalent required 
3+ years in HEDIS record collection and risk adjustment (coding) required 
 
Licenses/Certifications: 
One of the following required: CCS, LPN, LCSW, LMHC, LMSW, LMFT, LVN, RN, APRN, HCQM, CHP, CPHQ, CPC, CPC-A or CBCS
Pay Range: $27.02 - $48.55 per hour
Centene 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, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
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</div>

Quality Practice Advisor

<div>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&rsquo;ll have access to competitive benefits including a fresh perspective on workplace flexibility. 
Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT
This role requires local travel. This Qualified candidate must reside in one of the following counties or surrounding areas within the state of Maine: Aroostook or Androscoggin
Position Purpose: 
Serves as a vital link between members and the healthcare system, focusing on improving health outcomes by identifying and closing care gaps. This role emphasizes community engagement, member education, and collaboration with providers and internal teams to ensure members receive timely, appropriate care and support.<ul><li>
Conduct outreach to members in the community to identify care gaps and connect them with appropriate healthcare services and resources.</li><li>
Perform home visits or community-based assessments to evaluate member needs and identify social determinants of health that may prevent members from accessing preventive or follow-up care, and facilitate care coordination.</li><li>
Serve as a member advocate by helping individuals navigate complex healthcare and social service systems. Assist with scheduling appointments, understanding care plans, and accessing benefits or entitlements, ensuring members receive the support needed to close care gaps and maintain continuity of care</li><li>
Collaborate with providers to share quality performance data (e.g., HEDIS, CAHPS) and support improvement initiatives.</li><li>
Educate members on preventive care, chronic condition management, and available community resources.</li><li>
Document member interactions, care gap closures, and referrals in the appropriate systems.</li><li>
Partner with internal departments (e.g., Quality, Care Management, Provider Relations) to align efforts and improve member outcomes.</li><li>
Monitor and report on outreach effectiveness and care gap closure metrics.</li><li>
Maintain compliance with state and federal regulations and organizational policies.</li><li>
Participate in seasonal campaigns and quality initiatives to improve member engagement and health outcomes.</li><li>
Serve as a community ambassador, building relationships with local organizations and stakeholders.</li><li>
Performs other duties as assigned.</li><li>
Complies with all policies and standards.</li></ul>
Education/Experience: 
Bachelor's Degree Social Work, Public Health, Nursing, or related field; or equivalent experience required 
2+ years In community health or healthcare quality required 
Experience working with health plan members and navigating community resources required 
Familiarity with Medicaid / Medicare programs and quality measures (e.g., HEDIS) required 
Strong communication and interpersonal skills 
 
Licenses/Certifications: 
LCSW- License Clinical Social Worker preferred 
RN - Registered Nurse - State Licensure and/or Compact State Licensure preferred
Pay Range: $27.02 - $48.55 per hour
Centene 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, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
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</div>

Quality Care Member Advocate

<div>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&rsquo;ll have access to competitive benefits including a fresh perspective on workplace flexibility. 
Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT.
Position Purpose: Responsible for analytic data needs of the business unit. Handle complex data projects and acts as a lead for other Data Analysts.<ul><li>
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</li><li>
Extract, load, model, and reconcile large amounts of data across multiple system platforms and sources</li><li>
Review data to determine operational impacts and needed actions; elevate issues, trends, areas for improvement and opportunities to management</li><li>
Develop reports and deliverables and make recommendations to management</li><li>
Model data using MS Excel, Access, SQL, and/or other data ware house analytical tools</li><li>
Assist management in driving business decisions based on data</li><li>
Ensure compliance with federal and state deliverable reporting requirements by performing data quality audits and analysis</li><li>
Assist with training and mentoring other Data Analysts</li><li>
Assist with determining work load and related activities for other Data Analysts</li><li>
Performs other duties as assigned</li><li>
Complies with all policies and standards</li></ul>
Education/Experience: Bachelor&rsquo;s degree in related field or equivalent experience. 6+ years of statistical analysis or data analysis experience. Healthcare experience preferred. Experience managing projects or heavy involvement in project implementation. Experience mentoring, training and or leading teams highly preferred.
By applying to this requisition, you acknowledge and understand that you may be considered for other job opportunities for which Centene believes you may be qualified.
Pay Range: $87,700.00 - $157,800.00 per year
Centene 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, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
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</div>

Data Analyst IV Advanced SQL

<div>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&rsquo;ll have access to competitive benefits including a fresh perspective on workplace flexibility. 
***POSITION IS REMOTE BUT CANDIDATE MUST RESIDE IN STATE OF MISSOURI***
***POSITION WILL SUPPORT BEHAVIORAL HEALTH MEDICAID POPULATION AGES BIRTH TO 64****
Position 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 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 &ndash; 4 years of related experience. 
 
License/Certification:<ul><li>
Licensed Master's Behavioral Health Professional (e.g., LCSW, LMSW, LMFT, LMHC, LPC) or RN based on state contract requirements with BH experience required</li></ul>
Pay Range: $56,200.00 - $101,000.00 per year
Centene 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, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
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</div>

Care Manager (Behavioral Health)

<div>You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. 
<div>This is a remote position. Weekend position with flexible shift options. Applicants may work four 10-hour shifts or five 8-hour shifts per week. Availability to work Saturdays and Sundays is required</div><div></div>
Position Purpose: Performs a clinical review and assesses care related to mental health and substance abuse. Monitors and determines if level of care and services related to mental health and substance abuse are medically appropriate.<ul><li>
Evaluates member&rsquo;s treatment for mental health and substance abuse before, during, and after services to ensure level of care and services are medically appropriate</li><li>
Performs prior authorization reviews related to mental health and substance abuse to determine medical appropriateness in accordance with regulatory guidelines and criteria</li><li>
Performs concurrent review of behavioral health (BH) inpatient to determine overall health of member, treatment needs, and discharge planning</li><li>
Analyzes BH member data to improve quality and appropriate utilization of services</li><li>
Provides education to providers members and their families regrading BH utilization process</li><li>
Interacts with BH healthcare providers as appropriate to discuss level of care and/or services</li><li>
Engages with medical directors and leadership to improve the quality and efficiency of care</li><li>
Formulates and presents cases in staffing and integrated rounds</li><li>
Performs other duties as assigned.</li><li>
Complies with all policies and standards.</li></ul>
Education/Experience: Requires Graduate of an Accredited School Nursing or Bachelor's degree and 2 &ndash; 4 years of related experience. 
 
License to practice independently, and/or have obtained the state required licensure as outlined by the applicable state required. 
Master&rsquo;s degree for behavioral health clinicians required. 
Clinical knowledge and ability to review and/or assess treatment plans related to mental health and substance abuse preferred. 
Knowledge of mental health and substance abuse utilization review process preferred. 
Experience working with providers and healthcare teams to review care services related to mental health and substance abuse preferred. 
 
License/Certification:<ul><li>
LCSW- License Clinical Social Worker required or</li><li>
LMHC-Licensed Mental Health Counselor required or</li><li>
LPC-Licensed Professional Counselor required or</li><li>
Licensed Marital and Family Therapist (LMFT) required or</li><li>
Licensed Mental Health Professional (LMHP) required or</li><li>
RN - Registered Nurse - State Licensure and/or Compact State Licensure required</li><li>
For Fidelis Care only: LMSW, LCSW, LMHC, LPC, LMFT, LMHP or RN required</li></ul>
Pay Range: $27.02 - $48.55 per hour
Centene 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, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
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</div>

Utilization Review Clinician - Behavioral Health

Join Centene and explore 16   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.