Centene Job title: Critical Incident Specialist
WD Job Code: 800216
This role will be responsible for the development, implementation, resolution and oversight of waiver incident reporting at member level and organizational level. The primary functions will include waiver incident reporting education, incident reporting, incident investigation, incident processing and closure. This position ensures compliance with our CHC Agreement along with the Administrative Code and CMS regulations delegated.
Key Duties and Responsibilities
• Upon receipt of new case assignment, confirm eligibility and validate event qualifies for reporting
• Review historical events and determine if Trend Analysis is required
• Maintain internal documentation regarding investigation process status
• Collaborate and support Service Coordinators with investigation process
• Maintain open case volume and evaluate open cases for potential closure
• Closure of event may be completed when the following criteria are met: Actions taken to secure the health and safety of the participant; Measures taken to prevent or mitigate recurrence of the critical incident, including appropriate referrals; changes made to the Person-Centered Service Plan as a result of the incident
• No further action is required when the following conditions are satisfied: The facts and sequence of events is outlined with sufficient detail; Preventative action is implemented and documented; The participant is not placed at any additional risk
Required for All Jobs
• Performs other duties as assigned
• Complies with all policies and standards
MINIMUM QUALIFICATIONS
Education/Experience
Must have at least two years of experience and knowledge of waiver. Background in the field of Nursing, Social Work, and Case Management is preferred.
Clinical licensure is preferred but is not required. Clinical experience in lieu of licensure will be considered.
EEO:
“Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.”
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This role will be responsible for the development, implementation, resolution and oversight of waiver incident reporting at member level and organizational level. The primary functions will include waiver incident reporting education, incident reporting, incident investigation, incident processing and closure. This position ensures compliance with our CHC Agreement along with the Administrative Code and CMS regulations delegated.
Story Behind the Need – Business Group & Key Projects
- Health plan or business unit
- Team culture
- Surrounding team & key projects
- Purpose of this team
- Reason for the request
- Motivators for this need
- Any additional upcoming hiring needs?
The PHW Critical Incident (CI) Management team plays an essential role in supporting the Service Coordination department by ensuring comprehensive oversight of each critical incident. This includes timely and thorough screening, assessment, risk evaluation, mitigation planning, follow-up, and evaluation of outcomes for all reported events.
In tandem with these staffing constraints, the team continues to support internal quality improvement efforts and respond to the evolving standards set forth by OLTL. Since mid-2023, OLTL has reinforced statewide expectations around incident investigation, documentation, and quality assurance, increasing the demand for detailed, timely, and compliant reporting.
Additionally, since May 2023, the CI report volume has increased by approximately 25%, a trend that has continued into 2024 and appears consistent through Q1 of 2025. This surge, without corresponding staffing increases, has led to an average CIS-to-case ratio of 1:120. This is significantly above the sustainable and recommended ratio of 1:80, and even further from PHW’s internal case management model of 1:73. While CIS staff are not case managers by title, their responsibilities align closely in terms of managing risk and improving member outcomes, making adherence to similar caseload standards critical.
Typical Day in the Role
- Daily schedule & OT expectations
- Typical task breakdown and rhythm
- Interaction level with team
- Work environment description
This is a remote position consisting of a combination of independent and collaborative work responsibilities. Daily schedule is 8am-5pm, Monday-Friday. This contingent role will not be eligible for OT.
Typical task overview:
Upon receipt of new case assignment, confirm eligibility and validate event qualifies for reporting
Review historical events and determine if Trend Analysis is required
Maintain internal documentation regarding investigation process status
Collaborate and support Service Coordinators with investigation process
Maintain open case volume and evaluate open cases for potential closure
Closure of event may be completed when the following criteria are met: Actions taken to secure the health and safety of the participant; Measures taken to prevent or mitigate recurrence of the critical incident, including appropriate referrals; changes made to the Person-Centered Service Plan as a result of the incident
No further action is required when the following conditions are satisfied: The facts and sequence of events is outlined with sufficient detail; Preventative action is implemented and documented; The participant is not placed at any additional risk
Compelling Story & Candidate Value Proposition
- What makes this role interesting?
- Points about team culture
- Competitive market comparison
- Unique selling points
- Value added or experience gained
This is a very engaged and supportive team. The work is challenging, focused on quality outcomes, and affords opportunity to collaborate with various team members and across teams.
Candidate Requirements
Education/Certification
Required: Must have at least two years of experience and knowledge of waiver.
Preferred: Background in the field of Nursing, Social Work, and Case Management is preferred.
Licensure
Required:
Preferred: Nurse and/or Social Work
- Years of experience required
- Disqualifiers
- Best vs. average
- Performance indicators
Must haves: at least two years of experience and knowledge of waiver. Background in the field of Nursing, Social Work, and Case Management
FOCUS IN LTS
Nice to haves: Clinical licensure is preferred but is not required. Clinical experience in lieu of licensure will be considered.
Disqualifiers: no clinical background or experience in waiver processes.
Performance indicators:
Best vs. average:
- Top 3 must-have hard skills
- Level of experience with each
- Stack-ranked by importance
- Candidate Review & Selection
1
Clinical Background
2
Case Management Experience
3
Waiver Experience/Knowledge
Candidate Review & Selection
- Shortlisting process
- Second touchpoint for feedback
- Interview Information
- Onboard Process and Expectations
Projected HM Candidate Review Date:
Number and Type of Interviews:
Extra Interview Prep for Candidate:
Required Testing or Assessment (by Vendor):
Manager Communication Preferences & Next Steps
- Background Check Requirements (List DFPS or other specialty checks here)
As per clinical licensure requirements per state.
- Do you have any upcoming PTO?
No
