Qureos Mentor

Centene

<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. 
Please note: this is a remote role with preference on candidates located in Texas.
Position Purpose: Investigate allegations of potential healthcare fraud and abuse activity. Assist in planning, organizing, and executing claims investigations or audits that identify, evaluate and measure potential healthcare fraud and abuse.<ul><li>
Conduct investigations of potential waste, abuse, and fraud</li><li>
Document activity on each case and refer issues to the appropriate party</li><li>
Perform data mining and analysis to detect aberrancies and outliers in claims</li><li>
Develop new queries and reports to detect potential waste, abuse, and fraud</li><li>
Provide case updates on progress of investigations and coordinate with Health Plans on recommendations and further actions and/or resolutions</li><li>
Assist with complex allegations of healthcare fraud</li><li>
Prepare summary and/or detailed reports on investigative findings for referral to Federal and State agencies</li><li>
Complete various special projects and audits</li><li>
Performs other duties as assigned.</li><li>
Complies with all policies and standards.</li></ul>
Education/Experience: 
Bachelor's Degree Business, Criminal Justice, Healthcare, or related field, or equivalent experience required. 1+ years Medical claim investigation, medical claim audit, medical claim analysis, or fraud investigation required.
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>

SIU Investigator

<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 NATIONWIDE***
***CANDIDATE MUST HAVE 2+ YEARS FRAUD, WASTE AND ABUSE EXPERIENCE***
Position Purpose: Conduct comprehensive reviews of medical records and documents supporting claims for providers, suppliers, and pharmacies to include but not limited to physicians, inpatient, outpatient, ancillary, behavioral health care, laboratory, etc. Provides investigative support to the Special Investigations Unit (SIU) related to coding and billing issues and identifies potential overpayments and suspected health care fraud and abuse. Position requires the associate to verify authorization for services and written documentation of services provided against claim information, ensure the appropriateness and accuracy of diagnosis and procedure codes supporting such claims, coordinate medical necessity and appropriate level of care determinations with Medical Directors, and validate services against CMS and State-specific coverage, limitations and exclusion guidelines. Coordinate with internal and external resources in determining the appropriateness of codes found in administrative, medical, claim and financial records, develop reports of findings and recommendations, communicate complex results of audit findings in meetings and/or judicial hearings, and assist SIU investigators during interviews, discussions and negotiations with providers, suppliers, and pharmacies.<ul><li>
Perform retrospective and prepayment reviews of medical records to identify potential fraud, waste, and abuse and inappropriate billing practices.</li><li>
Investigate, analyze, and identify provider billing patterns to determine payment based on medical records, claim history, billing codes, regulatory and state guidelines, and policies.</li><li>
Prepare summary of findings and recommend next steps for providers.</li><li>
Identify preventative measures and recommend changes to internal policies and procedures and/or provider practices to prevent future fraudulent and erroneous practices.</li></ul><ul><li>
Collaborate with investigators to identify abuse and fraud by utilizing clinical and coding expertise to analyze patterns in billing activities.</li><li>
Performs other duties as assigned</li><li>
Complies with all policies and standards</li></ul>
Education/Experience: Master&rsquo;s Degree and 2 years of relevant experience required. 2+ years clinical experience with independent license required; 2 years of fraud, waste, and abuse experience required; experience in provider education and managed care organization preferred; coding certification preferred. 
 
License/Certification: Behavioral health license - LMHC, LCSW, LMFT, LPC, LMHP, LIMHP
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>

Clinical Investigator - 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. 
Position Purpose: Supervises Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members. Supervises day-to-day activities of utilization management team.<ul><li>
Monitors and tracks UM resources to ensure adherence to performance, compliance, quality, and efficiency standards</li>
<li>Collaborates with utilization management team to resolve complex care member issues</li>
<li>Maintains knowledge of regulations, accreditation standards, and industry best practices related to utilization management</li>
<li>Works with utilization management team and senior management to identify opportunities for process and quality improvements within utilization management</li>
<li>Educates and provides resources for utilization management team on key initiatives and to facilitate on-going communication between utilization management team, members, and providers</li>
<li>Monitors prior authorization, concurrent review, and/or retrospective clinical review nurses and ensures compliance with applicable guidelines, policies, and procedures</li>
<li>Works with the senior management to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services</li>
<li>Evaluates utilization management team performance and provides feedback regarding performance, goals, and career milestones</li>
<li>Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards</li>
<li>Assists with onboarding, hiring, and training utilization management team members</li>
<li>Leads and champions change within scope of responsibility</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 4+ years of related experience. 
 
Knowledge of utilization management principles preferred. 
 
License/Certification:<ul><li>
RN - Registered Nurse - State Licensure and/or Compact State Licensure required</li><li>
CA RN LICENSE REQUIRED</li></ul>
Pay Range: $75,300.00 - $135,400.00 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, Utilization Management (RN)

<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. 
Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.<ul><li>
Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care</li>
<li>Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member</li>
<li>Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered</li>
<li>Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines</li>
<li>Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings</li>
<li>Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members</li>
<li>Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines</li>
<li>Reviews member&rsquo;s transfer or discharge plans to ensure a timely discharge between levels of care and facilities</li>
<li>Collaborates with care management on referral of members as appropriate</li><li>
Performs other duties as assigned.</li>
<li>Complies with all policies and standards.</li></ul>
We are seeking a Clinical Review Nurse - Concurrent Review to join our team!
The ideal candidate will bring expertise in:
IL Nursing License
 
Concurrent Review
 
Inpatient Authorizations 
Discharge Planning 
Acute and/or Critical Care
 
Computer Savvy
 
Excellent Customer Service and Communication Skills
Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor&rsquo;s degree in Nursing and 2 &ndash; 4 years of related experience. 2+ years of acute care experience required. 
 
Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. 
Knowledge of Medicare and Medicaid regulations preferred. 
Knowledge of utilization management processes preferred. 
 
License/Certification:<ul><li>
LPN - Licensed Practical Nurse - State Licensure 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>

Clinical Review Nurse - Concurrent Review

<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***
***IDEAL CANDIDATE WILL BE LPN WITH EXPERIENCE SUPPORTING INFANCY TO 15 MONTHS PEDIATRIC POPULATION***
Position Purpose: Develops, assesses, and coordinates care management activities based on member needs to provide quality, cost-effective healthcare outcomes. Develops or contributes to the development of a personalized care plan/service plan for members and educates members and their families/caregivers on services and benefit options available to improve health care access and receive appropriate high-quality care through advocacy and care coordination.<ul><li>
Evaluates the needs of the member, barriers to care, the resources available, and recommends and facilitates the plan for the best outcome</li><li>
Develops or contributes to the development of a personalized care plan/service ongoing care plans/service plans and works to identify providers, specialists, and/or community resources needed for care</li><li>
Provides psychosocial and resource support to members/caregivers, and care managers to access local resources or services such as: employment, education, housing, food, participant direction, independent living, justice, foster care) based on service assessment and plans</li><li>
Coordinates as appropriate between the member and/or family/caregivers and the care provider team to ensure identified care or services are accessible to members in a timely manner</li><li>
May monitor progress towards care plans/service plans goals and/or member status or change in condition, and collaborates with healthcare providers for care plan/service plan revision or address identified member needs, refer to care management for further evaluation as appropriate</li><li>
Collects, documents, and maintains all member information and care management activities to ensure compliance with current state, federal, and third-party payer regulators</li><li>
May perform on-site visits to assess member&rsquo;s needs and collaborate with providers or resources, as appropriate</li><li>
May provide education to care manager and/or members and their families/caregivers on procedures, healthcare provider instructions, care options, referrals, and healthcare benefits</li><li>
Other duties or responsibilities as assigned by people leader to meet the member and/or business needs</li><li>
Performs other duties as assigned.</li><li>
Complies with all policies and standards.</li></ul>
Education/Experience: Requires a Bachelor&rsquo;s degree and 2 &ndash; 4 years of related experience. Requirement is Graduate from an Accredited School of Nursing if holding clinical licensure. 
 
Or equivalent experience acquired through accomplishments of applicable knowledge, duties, scope and skill reflective of the level of this position. 
 
License/Certification:<ul><li>
Current state&rsquo;s clinical license preferred</li></ul>
Pay Range: $22.94 - $38.79 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>

Care Navigator (LPN)

<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: Analyze integrated and extensive datasets to extract value, which directly impacts and influences business decisions. Work collaboratively with key business stakeholders to identify areas of value, develop solutions, and deliver insights to reduce overall cost of care for members and improve their clinical outcomes. This Data Analyst II focuses on enterprise provider analytics to measure and report the actual impact of contract and network changes against projected outcomes. The team delivers standardized, structured reporting to track implementation accuracy and validate savings. With clearly defined initiatives and QAIs, the goal is consistent measurement to support network strategy and business decision-making.<ul><li>
Interpret and analyze data from multiple sources including healthcare provider, member/patient, and third-party data</li><li>
Support execution of large-scale projects with limited direction from leadership</li><li>
Identify and perform root-cause analysis of data irregularities and present findings and proposed solutions to leadership and/or customers</li><li>
Manage multiple, variable tasks and data review processes with limited supervision within targeted timelines</li><li>
Support the design, testing, and implementation of process enhancements and identify opportunities for automation</li><li>
Apply expertise in quantitative analysis, data mining, and the presentation of data to see beyond the numbers and understand how customers interact with analytic products</li><li>
Support multiple functions and levels of the organization and effectively, both verbally and visually, communicate findings and insights to non-technical business partners</li><li>
Independently engage with customers and business partners to gather requirements and validate results</li><li>
Communicate and present data-driven insights and recommendations to both internal and external stakeholders, soliciting and incorporating feedback when required</li><li>
Performs other duties as assigned</li><li>
Complies with all policies and standards</li></ul>
Education/Experience: Bachelor&rsquo;s degree in business, economics, statistics, mathematics, actuarial science, public health, health informatics, healthcare administration, finance or related field or equivalent experience. 2+ years of experience working with large databases, data verification, and data management, or 1+ years IT experience. Healthcare analytics experience preferred. Working knowledge of SQL/query languages. Preferred knowledge of programmatic coding languages such as Python and R. Knowledge of statistical, analytical, or data mining techniques including basic data modeling, trend analysis, and root-cause analysis preferred. Preferred knowledge of modern business intelligence and visualization tools. Experience in emerging trend analysis, financial modeling, claims pricing, contract/network analysis, and/or ROI evaluation preferred. Familiarity with claims payment, utilization management, provider/vendor contracts, risk adjustment for government sponsored healthcare desired.
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: $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>

1636425 Data Analyst II Healthcare Analytics, Provider Analytics

Join Centene and explore 6   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.