Job Description

Position Purpose: The position is responsible for providing leadership and direction for clinical, quality, and risk adjustment functions. Execute on the development and oversight of clinical programs for physician education and communication as well as development of their team in activities to increase member quality of care, reduce costs, and identify risk adjustment opportunities. Provide and analyze reports to identify trends, opportunities and recommend actions.

• Coordinates with other departments to prioritize provider engagement, communication opportunities of all clinical, quality, risk adjustment projects.
• Establishes and maintains tracking and monitoring systems for health care quality improvement activities according to regulatory requirements, risk adjustment, policies and procedures and contractual agreements.
• Ensures high-risk, high-volume, and unusual events are monitored concurrently and retrospectively as they occur.
• Manages and evaluates performance of staff related to clinical and health care services performance improvement activities.
• Provides guidance, training, and development to all department associates.
• Coordinates guidelines, studies and performance improvement activities in concert with the quality management, pharmacy services, and risk management programs.
• Maintains a knowledge base of HEDIS requirements and implementing clinical performance methods to improve HEDIS performance.
• Coordinates all external programmatic oversight visits for contracted providers and ensures timely completion and follow up on corrective action plans.

Education/Experience: A bachelor’s degree in Health Care, Nursing, Public Health Administration or Business, or equivalent work experience is required.
3 or more years of supervisory/management experience.
5+ years’ experience working in a managed care environment.

Registered Nurse, Certified Health Care Risk Management certification, Foreign MD, or American Academy of Professional Coders certification preferred.Pay Range: $87,700.00 - $157,800.00 per year

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.

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