Jobs at Centene Corporation

Lead analytics for Internal Audit Claims: extract, transform, reconcile, and validate large claims datasets; build and maintain Power BI reports/dashboards; perform QA and tie-outs; support automation, bots/AI enablement, and executive reporting; mentor other analysts and partner with audit, IT, and business stakeholders to deliver repeatable, validated analytics.

Supports healthcare quality improvement projects, reporting, audits, and medical record reviews. Analyzes and trends quality results, prepares management and ad hoc reports, develops improvement plans, trains providers and staff, responds to inquiries, and participates in meetings with state agencies and stakeholders. The role requires knowledge of HEDIS, audit processes, and quality improvement methodologies, with three or more years of related experience.

Leads business strategy transformation by identifying improvement opportunities, assessing capability gaps, designing solutions, developing business cases, and governing business architecture. Elicits and documents requirements, facilitates workshops, coordinates cross-functional initiatives, and supports launches and process improvements. Maintains architecture models, tracks expected versus realized business value, and advises senior leadership on strategies and outcomes.

Audit provider claims against eligibility records, enrollment data, contracts, billing manuals, and other source documents to identify payment errors. Analyze root causes, assign error responses, document audit observations using audit software, validate responses, and update audit criteria and pricing tools based on state policy changes. The role requires claims pricing or processing knowledge, contract interpretation, and familiarity with Medicaid, Medicare, CPT, and HCPCS coding.

Reviews medical necessity grievances, appeals, and denials using clinical information, company policies, and NCQA guidelines. Determines whether denials should be upheld or overturned, prepares cases for Medical Director review, communicates appeal resolutions, identifies quality-of-care concerns, supports corrective actions, requests provider information, prepares Administrative Law Hearing materials, and maintains required appeals timelines and records.

Direct LTSS business development, market expansion, proposal strategy, deal closing, licensing, implementation, risk mitigation, and regional business planning. Build relationships with providers, advocates, community leaders, regulators, and elected officials while overseeing staff and measuring project performance. Requires extensive healthcare market knowledge, leadership experience, and 75% travel.

Manages a care management team and member care programs to achieve compliant, high-quality, cost-effective healthcare outcomes. Oversees documentation, escalations, complex cases, audits, policies, reporting metrics, staff caseloads, and regulatory compliance. Supports hiring, onboarding, training, and team development while coordinating with members, providers, and senior leadership. The role is remote and requires California RN licensure while working Pacific Time hours.

Act as a liaison to improve pharmacy quality performance, collaborating with providers and pharmacies, and ensuring timely insights while managing territory engagement plans.

Provide clinical data analysis, audits, and workflow recommendations to ensure compliance (HEDIS, URAC, NCQA). Design data pulls, produce analytical and audit reports, support corrective action plans, training, and regulatory audit preparation. Collaborate with clinical teams and data analysts to track performance, forecast staffing, and improve operational processes.

Review psychological testing and treatment documentation for medical necessity and quality; authorize and monitor outpatient behavioral health and substance abuse care; conduct peer reviews; consult with providers and Medical Director; educate network practitioners on best practices and utilization management; respond to complaints and provide clinical oversight for outpatient services.

The Senior Business Systems Analyst collaborates with stakeholders to translate complex requirements into technical specifications, ensuring alignment with strategic goals. Responsibilities include gathering business requirements, creating process models, managing project lifecycles, and providing user support.

Lead pharmacy operations across multiple markets and products, develop and implement pharmacy benefit management programs, manage vendor contracts and accreditation participation, analyze utilization and financial data, oversee pharmacy staff, and support provider education and budget planning to achieve organizational pharmacy and medical goals.

Remote psychologist reviewer specializing in ABA for youth with Autism. Authorize, direct, and monitor behavioral health services; conduct peer reviews; educate network providers; consult with Medical Director; respond to complaints; provide clinical oversight of outpatient services.

Lead and oversee the Gold Card Program, driving long-term program development, integration across business units, and ensuring consumer experience, clinical, and engineering expertise inform product design. Manage adaptive technology integration, team-based services for behavior change outcomes, and evaluate financial performance and value propositions for program enhancements and new development.

Remote psychologist reviewer authorizes and monitors behavioral health/ABA care, conducts peer reviews, provides clinician education on best practices and utilization management, responds to complaints, collaborates with Medical Director, and offers clinical oversight for outpatient services.

Supervise utilization management nursing team handling prior authorization, concurrent and retrospective reviews. Ensure compliance with regulations and quality standards, coach and evaluate staff, lead process improvements, assist hiring and training, and collaborate with senior management on UM policies and complex member care issues.