Centene Corporation

• Deliver rapid quality and process improvement information to the technicians on their team • Prepare material for and deliver in team meetings • Serve as a subject matter expert for their team • Provide guidance to pharmacy technicians on quality assurance monitoring and productivity standards • Track and triage coverage determination requests submitted from providers • Obtain verbal authorizations and request detailed clinical information from prescribers • Approve coverage determination requests based on defined criteria • Document coverage determination request decision into the PBM system and notify providers and/or members • Respond to client inquiries regarding authorization approvals and PBM on-line applications • Refer coverage determination requests for specialty drugs to delegated vendor or client for processing • Perform other duties as assigned

• Ensure administration of the pharmacy program is accurate and compliant by supporting various operational tasks • Perform duties to support the development, coordination and maintenance of the pharmacy program • Review benefit/formulary setup and testing (new and year over year) • Conduct claims analysis • Perform other duties as assigned • Comply with all policies and standards

• conduct prior authorization reviews for ABA treatment services • evaluate clinical documentation for medical necessity • monitor clinical effectiveness and efficiency of member's care according to ABA guidelines • analyze BH member data to improve service utilization • interact with BH healthcare providers to discuss care and services

• Directs the utilization management team to ensure the appropriate application of policy procedures and processes • Oversees and manages Utilization Operations specific to the daily operations of Utilization Management • Leads utilization management team on performance, improvement, and career growth path considerations • Reviews, analyzes, and reports on utilization trends, patterns, and impacts to deliver an effective utilization program • Establishes policies and procedures that incorporate best practices • Develops utilization management strategies and influences decisions by providing recommendations • Responsible for components of the department’s budget while collaborating inter-departmentally with senior leadership • Executes the overall strategy for onboarding, hiring, and training new utilization management team members • Leads and champions change within scope of responsibility

Role Description Responsible for the growth and performance of assigned mid/high complexity and revenue Medicare markets within a region, driving enterprise goals in membership, earnings, quality, network performance, provider experience, and compliance. - Develop and execute market-specific strategies. - Foster cross-functional collaboration. - Develop strong internal and external partnerships with key stakeholders. - Drive operational excellence. - Balance strategic vision with disciplined execution. - Lead and organize a multi-disciplinary, cross-functional team to achieve results. - Represent the Medicare and D-SNP business with authenticity, accountability, and results orientation. - Responsible for the P&L management of assigned markets, including management of clinical, financial, and key operational performance. - Develop market-specific strategic operating plans with KPIs, milestones, and governance processes that support organizational goals. - Lead expansion and performance of value-based care initiatives. - Lead expansion and performance of D-SNP initiatives. - Provide leadership direction and vision to innovate and improve the performance of the business. - Monitor and analyze the changing landscape and recommend strategies and programs to proactively address the changing needs of the markets (Provider & Members). - Drive quality initiatives aligned with STAR outcomes and continuous improvement. - Build collaborative and effective partnerships with internal and external stakeholders. - Identify the appropriate strategic approach to drive business growth and differentiate the product in the assigned markets. - Work collaboratively with product, shared services, and market leaders to ensure that Medicare enterprise-wide networks, quality and risk, clinical, operational, financial, and leadership expectations are met. - Provide effective leadership to direct and matrixed teams, fostering a culture of collaboration, innovation, and accountability. - Perform other duties as assigned. - Comply with all policies and standards. Qualifications - Bachelor's Degree in Business Administration, Healthcare Administration, or other related field or equivalent experience required. - Over 10 years of leadership experience in cross-functional initiatives. - More than 5 years in marketing, sales, and/or product development. - Proven track record of identifying and driving growth-enabling strategies. - Demonstrated success in business development through forging long-term strategic alliances and partnerships that have significantly increased revenue. Requirements - Equivalent experience acquired through accomplishments of applicable knowledge, duties, scope, and skill reflective of the level of this position. - Proven history of identifying growth-enabling initiatives and opportunities. - Business development experience required. Benefits - Competitive pay. - Health insurance. - 401K and stock purchase plans. - Tuition reimbursement. - Paid time off plus holidays. - Flexible approach to work with remote, hybrid, field, or office work schedules. - Total compensation may include additional forms of incentives. - Benefits may be subject to program eligibility.

• Supports the goals and outcomes of the organization by leading the transformation of our business strategy • Ensures deliverables are met, by assisting with design, execution, and value estimation and realization for initiatives • Partner with business leaders to identify opportunities for improvement • Evaluate, assess, and design solutions • Assist in value estimation, cost-benefit analysis, and business case creation • Establish and maintain business architecture governance • Coordinate across business and delivery groups to ensure timely completion of key deliverables • Create and maintain core business architecture models, such as value streams, business capabilities, information maps, and strategy trees • Lead workshops the gather ideas, evaluate processes, and gather intelligence • Track and trend predicted business value versus actual value and business outcomes • Advise senior leadership on business strategies

• Perform various analysis and interpretation to link business needs and objectives for assigned function • Partner with IT, program managers, SMEs, and recovery vendors to translate operational needs into system enhancements, develop business requirements, manage issue resolution, and ensure timely support of recovery operations • Monitor recovery operations, inventory, and reporting tools to identify issues and savings opportunities, while leading defect investigation, user acceptance testing (UAT), and implementation of quality solutions to improve accuracy and performance • Support business initiatives through data analysis, identification of implementation barriers and user acceptance testing of new systems • Identify and analyze user requirements, procedures, and problems to improve existing processes • Perform detailed analysis on assigned projects, recommend potential business solutions and assist with implementation • Identify ways to enhance performance management and operational reports related to new business implementation processes • Develop and incorporate organizational best practices into business applications • Lead problem solving and coordination efforts between various business units • Assist with formulating and updating departmental policies and procedures

• 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 • Monitors and tracks UM resources to ensure adherence to performance, compliance, quality, and efficiency standards • Collaborates with utilization management team to resolve complex care member issues • Maintains knowledge of regulations, accreditation standards, and industry best practices related to utilization management • Works with utilization management team and senior management to identify opportunities for process and quality improvements within utilization management • Educates and provides resources for utilization management team on key initiatives and to facilitate on-going communication between utilization management team, members, and providers • Monitors prior authorization, concurrent review, and/or retrospective clinical review nurses and ensures compliance with applicable guidelines, policies, and procedures • Works with the senior management to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services • Evaluates utilization management team performance and provides feedback regarding performance, goals, and career milestones • Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards • Assists with onboarding, hiring, and training utilization management team members • Leads and champions change within scope of responsibility • Performs other duties as assigned • Complies with all policies and standards

• Supports the documentation and processing of appeals, disputes and reconsiderations • Ensures they are in accordance with state and NCQA requirements • Performs data entry to support the tracking, logging, and processing of appeals • Prepares correspondence for appeals, disputes and reconsiderations • Maintains documentation files and reviews requests • Conducts research needed to evaluate, process, and respond to appeals

• Authorize, direct and monitor care for behavioral health and/or substance abuse problems according to clinical information given by providers and internal criteria for medical necessity and appropriateness of care • Conduct peer reviews with psychologists, behavioral health therapists and/or Board Certified Behavior Analysts for outpatient services and/or psychological testing requests • Interact with network practitioners to provide education on best practice models and utilization management processes • Interact with the Medical Director, or designee, to discuss clinical authorization questions and concerns regarding specific cases • Respond to state, provider, and member complaints related to psychological testing or other services requiring review by a PhD/PsyD • Facilitate outpatient rounds offering clinical input and oversight related to outpatient services • Performs other duties as assigned. Complies with all policies and standards.