Centene Corporation

• Supports community connection activities including connecting members to community resources • Provides members with known community resources and supports the care team • Assists members to connect them to known community and care resources • Promotes awareness of care/services and supports all member related correspondence • Documents and maintains community resources to ensure standards of practice • Provides assistance to the clinical team and conducts non-clinical general health assessments • Conducts both telephonic and/or in-person outreach to locate individuals and families • Performs other duties as assigned

• Develops, assesses and coordinates holistic care management activities • Evaluates member service needs and develops care plans/service plans • Acts as liaison and member advocate between member/family and healthcare providers • Performs frequent home and/or site visits to assess member needs • Provides education to long-term care members and their families on various topics • Ensures appropriate referrals based on individual member needs • Maintains accurate documentation in electronic care management system • Ensures compliance with clinical guidelines and state/federal guidelines

• Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and NCQA standards • Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal • Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards • Communicates with members, providers, facilities, and other departments regarding appeals requests • Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards • Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeals requests • Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices • Performs other duties as assigned • Complies with all policies and standards

• Responsible for developing and conducting a variety of training programs and/or auditing tools to provider-facing staff on quality programs, provider performance initiatives, provider tools, and field workflows • Conduct training evaluations and needs analyses to gather feedback to determine specific training needs and improve training effectiveness for department staff • Apply adult learning principles to create engaging, interactive learning experiences that strengthen confidence in provider conversations and improve consistency across teams • Support train-the-trainer needs for market or regional facilitators, when applicable, to enable scalable rollout of enterprise training and resources • Identify, select, develop, and maintain appropriate training programs, including the selection or design of appropriate training aids, presentations, user guides, e-learning modules, knowledge checks, and facilitation guides • Collaborate with subject matter experts to evaluate effectiveness and validate content accuracy, ensuring alignment with organizational standards • Translate complex quality program requirements into easy-to-understand training content • Partner with internal business teams to ensure training reflects current program standards, expectations, and updates • Support rollout of new quality initiatives through training, communication, and documentation • Research, analyze and recommend process improvements and enhancements to training resources to strengthen program outcomes • Maintain version control and update cadence for training and resources to ensure staff access current, approved materials • Maintain records of training activities and employee progress • Assist in auditing work performed by staff and present findings and recommendations for areas of improvement to management • Assist with revisions to policy and procedures and/or work process development. • Performs other duties as assigned. • Complies with all policies and standards.

• Oversee all direct processes of credentialing and provider data entry, from triage through provider enrollment and data maintenance • Direct oversight for credentialing and re-credentialing of all physicians, mid-level practitioners and organizational providers • Oversee all activities related to the management of provider data, including the development and management of training materials, policies, and procedures • Ensure updates (adds, changes, and terminations) for new or existing provider records are made in accordance with health plan policies and state/federal regulations • Ensure compliance with key performance indicators established by corporate office, NCQA credentialing standards, and state/federal requirements • Manage updates to and production of hard copy and online provider directories • Ensure accuracy of provider enrollment specifications and specialty types and demographics

• Provides resource support to members and connects them to local resources for services • Works with leadership to identify appropriate local resources based on needs • Assists with connecting members to local resources and documentation • Acts as a resource for members seeking support • Monitors delivery of services and performs follow up • Works with providers and community organizations to support members • Develops education and training programs for care management staff • Ensures resource services information is documented

• Serves as the LTSS subject matter expert, leading RFP development and submissions while supporting the design, implementation, and growth of LTSS programs • Directs the long-term care of members with physical/medical health needs and/or behavioral/mental health needs to develop and assess high quality, cost-effective healthcare outcomes • Develops strategies and objectives within long-term care management to improve member and/or provider experience • Provides leadership to the development, implementation, monitoring, and ongoing improvement of the long-term care management process • Sets goals and objectives for long-term care management team and oversees care management data and reporting metrics to achieve quality and cost-effective healthcare results and working with senior leadership • Leads long-term care management policies and procedures within the care management team to ensure compliance with corporate, state, and National Committee for Quality Assurance (NCQA) standards • Oversees and monitors work assignments and caseloads of long-term care management staff based on state requirements, care management staff experience, and member needs • Monitors, reviews, and signs off on contract required reporting as required

• Oversee activities of the provider contracting, network development and/or provider relations functions and aid in formulating and administering organizational policies and procedures • Oversee provider contracting activities to ensure efficiency and maintain compliance with the business unit’s policies and standards, government laws and regulations • Implement development activities for the recruitment and contracting of provider networks in new and prospective markets, and existing market expansions • Support new business launch in diverse markets while considering individual market circumstances, provider community, budgeting constraints and available resources • Perform complex financial analyses to identify medical cost improvement opportunities, develop strategies to reach financial goals, and execute contracting strategies to meet goals and objectives • Oversee contracting and network development staff and external consultants in the development of provider networks for new and expansion markets • Monitor performance, develop, and implement business solutions to address process and quality gaps, and communicate network strategy and planning • Ability to travel

• Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards • Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal • Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards • Communicates with members, providers, facilities, and other departments regarding appeals requests • Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards • Works with leadership to increase consistency, efficiency, and appropriateness of responses of all appeals requests • Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices • Performs other duties as assigned • Complies with all policies and standards

• Develops, assesses, and facilitates complex care management activities for primarily mental and behavioral health needs members • 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 • May perform telephonic, digital, home and/or other site visits outreach to assess member needs and collaborate with resources • Develops ongoing care plans for members with high level acuity and works to identify providers, specialists, and community resources needed for care • Monitors care plans/service plans and/or member status and outcomes for changes in treatment side effects, complications and clinical symptoms • Provides education to members and their families on procedures, healthcare provider instructions, treatment options, referrals, and healthcare benefits