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. *Qualified candidates for this role must be available to work 9:30AM-6:00PM EST. 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: The Pharmacy Resolution Specialist receives and responds to calls from members, provider/physician's offices, and pharmacies. This role makes outbound calls and enters pharmacy overrides into systems based on approved guidelines and approvals provided from clinical pharmacists. - Takes member/prescriber/pharmacist inquiry calls for benefit questions including prior authorization requests - Offers options including submission of a prior authorization request - Thoroughly researches issues and takes appropriate action to resolve them using the appropriate reference material within turnaround time requirements and quality standards - Logs, tracks, resolves, and responds to all assigned inquiries and complaints while meeting all regulatory, CMS, and Centene Corporate guidelines in which special care is required to enhance Centene relationships, while meeting and exceeding all performance standards - Maintains expert knowledge on all pharmacy benefits and formularies, including CMS regulations as they pertain to this position - Responsible for knowing and interpreting pharmacy and medical benefits - Answers and conducts inbound and outbound calls with members and provider offices to provide resolution to claims (i.e.: additional information requests and medication determination updates) - Actively involved in the initiation and providing status for prior authorization/coverage determination, appeal / redetermination phone calls - Responsible for ensuring outstanding attention to detail - Identify root cause issues to ensure enterprise solutions and communicate findings as needed to ensure first call resolution - Assists with special projects as assigned - Performs other duties as assigned - Complies with all policies and standards Education/Experience: High School Diploma / GED and 1 year of Job Specific call center/customer service. Pay Range: $15.87 - $27.25 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

Sanford Health is one of the largest and fastest-growing not-for-profit health systems in the United States. We’re proud to offer many development and advancement opportunities to our nearly 50,000 members of the Sanford Family who are dedicated to the work of health and healing across our broad footprint. Work Shift: 8 Hours - Day Shifts (United States of America) Scheduled Weekly Hours: 40 Salary Range: $16.50 - $23.00 Union Position: No Department Details Remote position working with clinics and insurance companies to provide care for our patients. Summary The Patient Access Specialist reviews and validates insurance eligibility, prior authorization and/or referral of medication, procedures, etc.; determines if insurance meets prior authorization criteria. Job Description Collects necessary documentation and communicates with third party payers, healthcare professionals and customers to prioritize requests. Verifies patient registration and confirms benefit coverage, including deductibles and out-of-pocket expenses; researches and verifies covered benefits for ordered tests, procedures, and other services. Responsible for assuring that prior authorization for medical services, including testing, procedures, surgery, Durable Medical Equipment (DME), and medications is completed and confirmed. Obtains diagnosis(es)/CPT code(s) from medical chart and/or provider office. Contacts third party payer to determine appropriate prior authorization process. Works closely with provider offices to obtain and clarify documentation to demonstrate medical necessity. If medical necessity criteria are not met, follows up with provider offices with guidance for Advanced Beneficiary Notices (ABN) or waivers that releases the financial burden of scheduled services from the facility to the patient. Reviews professional services denials; works with clinics and third party payers on appeal process. Assures all required referrals are in place; may work on outgoing referrals for care outside Sanford Health. May have minimal telephonic patient interaction concerning provider referrals. May notify appropriate insurance companies when patients have checked in for inpatient services and procedures requiring observation periods. Documents work in case management module; provides direction to utilization management, case management, and nursing regarding what action needs to be taken. Collaborates with case management, social work, utilization management, and other cross-functional teams across the enterprise. Assists with the design and management of data including the preparation of reports and presentations. Qualifications High school diploma or equivalent preferred; post-secondary education helpful. Minimum of two years of experience in a hospital or clinic setting required. Understanding of medical terminology, insurance background, office equipment and computers is required. Sanford is an EEO/AA Employer M/F/Disability/Vet. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-877-673-0854 or send an email to talent@sanfordhealth.org.

Remote Release of Information Specialist (ROIS) Summary of Position: The Release of Information Specialist I (ROIS I) initiates the medical record release process by inputting data into Verisma Software. The ROIS I works quickly and carefully to ensure documentation is processed accurately and efficiently. This position could be based out of a Verisma facility, at a client site, or in some instances may be done remotely. The primary supervisor is Manager of Operations, Release of Information. Duties & Responsibilities: - Process medical ROI requests in a timely and efficient manner - Process requests utilizing Verisma software applications - Support the resolution of HIPAA-related release issues - Organize records and documents to complete the ROI process - Read and interpret medical records, forms, and authorizations - Provide exemplary customer service in person, on the phone and via email, depending on location requirements - Interact with customers and co-workers in a professional and friendly manner - Utilize reference material provided by Verisma to ensure compliance and confidentiality is always maintained - Attend training sessions, as required - Live by and promote Verisma company values - Perform other related duties, as assigned, to ensure effective operation of the department and the Company Minimum Qualifications: - HS Diploma or equivalent, some college preferred - 2+ years of medical record experience - 2+ years of experience completing clerical or office work - Experience using general office equipment including desktop computer, scanner, Microsoft Office Suite to complete tasks - Experience in a healthcare setting, preferred - Knowledge of HIPAA and state regulations related to the release of Protected Health Information, preferred - Must be able to work independently - Must be detail oriented

Release of Information Specialist I (ROIS I) Summary of Position: The Release of Information Specialist I (ROIS I) initiates the medical record release process by inputting data into Verisma Software. The ROIS I works quickly and carefully to ensure documentation is processed accurately and efficiently. This position could be based out of a Verisma facility, at a client site, or in some instances may be done remotely. The primary supervisor is Manager of Operations, Release of Information. Duties & Responsibilities: - Process medical ROI requests in a timely and efficient manner - Process requests utilizing Verisma software applications - Support the resolution of HIPAA-related release issues - Organize records and documents to complete the ROI process - Read and interpret medical records, forms, and authorizations - Provide exemplary customer service in person, on the phone and via email, depending on location requirements - Interact with customers and co-workers in a professional and friendly manner - Utilize reference material provided by Verisma to ensure compliance and confidentiality is always maintained - Attend training sessions, as required - Live by and promote Verisma company values - Perform other related duties, as assigned, to ensure effective operation of the department and the Company Minimum Qualifications: - HS Diploma or equivalent, some college preferred - RHIT certification, preferred - 2+ years of medical record experience - 2+ years of experience completing clerical or office work - Experience using general office equipment including desktop computer, scanner, Microsoft Office Suite to complete tasks - Experience in a healthcare setting, preferred - Knowledge of HIPAA and state regulations related to the release of Protected Health Information, preferred - Must be able to work independently - Must be detail oriented