Job Description

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: Ensure the timely and safe transition of members into or out of the health plan. Assist in the transition of members back into the community from various levels of health care services.

• Manage the transition of care for members enrolling or exiting the health plan
• Identify new enrollee requiring transition of care services
• Complete assessment of the new Enrollee’s health care needs
• Determine the presence of active care needs or possible outstanding service authorizations
• Identify the Enrollee’s previous MCO (if applicable)
• Contact the previous MCO and/or Primary Care Provider (PCP) to obtain relevant Enrollee information (if applicable)
• Ensure existing authorizations with previous health plan or in fee-for-service are honored during the transition, for a minimum of 60 calendar days from the date of enrollment in the health plan
• Assist the enrollee with continuing authorization of medically necessary services, transitions into Integrated Care Program, transitions between MCOs, and transitions to private insurance or no coverage.
• Coordinate care plans with community care coordinators and the enrollee
• Educate transitioning enrollees about services, requirements, limitations and/or exclusions of services as a result of the transition.

Education/Experience: Bachelor’s degree in Social Work, Nursing, Health, Behavioral Science or equivalent experience. 3+ years of related experience. Experience working with Medicaid recipients with physical, developmental and intellectual disabilities and/or behavioral health conditions. Experience in insurance and utilization review.

License/Certification: Valid driver's license. Social Worker, LPN, LVN, or RN preferred.

For LA Healthcare Connections only - Valid driver's license preferred.:
For PA Health & Wellness plan: RN or LPN license required.

For North Carolina only: In addition, these individuals will assist members who are moving from one clinical setting to another to prevent unplanned or unnecessary readmissions, emergency department visits, or adverse outcomes. Must reside in NC.

Our Comprehensive Benefits Package: Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.

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.