Jobs at Centene Corporation

Perform risk-based internal audits using AI, automation, and data analytics. Design and implement AI-enabled audit procedures, dashboards, and reusable workflows; execute audits, draft reports, and recommend process improvements while validating AI outputs.

Provide strategic leadership for pharmacy operations across multiple facilities, managing pharmacists-in-charge, ensuring regulatory compliance, setting policies and budgets, analyzing operating costs, resolving cross-functional operational issues, and overseeing pharmacy communications, training, and performance management.

Lead and conduct enterprise-wide compliance and ethics investigations across business units and health plans. Assess allegations, review documents, interview witnesses, prepare investigation reports, recommend remediation or discipline, track corrective actions, maintain case files in centralized systems, produce metrics and presentations, and collaborate with cross-functional stakeholders to ensure regulatory defensibility.

Partner with health plans to drive pharmacy quality measures across lines of business. Provide clinical and quality expertise, develop and present performance reviews, coordinate initiatives across markets and enterprise teams, identify improvement opportunities, and train provider-facing teams to accelerate pharmacy measure performance.

Lead enterprise-wide process improvement initiatives using LEAN/Six Sigma, PDSA and DMAIC. Facilitate cross-functional teams, collect and analyze KPIs, implement training and maintenance plans, prioritize projects, and report process gaps and status to management.

Lead a team providing first-line oversight of regulatory reporting, audits, and risk management. Advise senior leadership on regulatory impacts, monitor remediation (Archer findings), develop policies and corrective action plans, and drive scalable, compliant operations and continuous improvement.

Manage and develop standard and custom formularies across Commercial, Medicaid, Medicare Part D and marketplace lines. Review drug literature and utilization trends, create formulary recommendations, prior authorization criteria, clinical edits, and reports. Support P&T committee processes, provide clinical guidance to pharmacy technicians, and ensure regulatory and fraud/abuse reporting compliance.

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.

12-week Clinical Externship observing preceptors and participating in projects to learn managed care processes and clinical services. Develop clinical knowledge and hands-on experience by shadowing, following preceptor guidance, and completing assigned tasks per company procedures. Requires enrollment in an accredited clinical program and course credit for the externship.

Perform actuarial analysis, pricing, and risk assessment to support Value-Based Care initiatives. Develop valuation methodologies, build end-to-end models from claims and clinical data, ensure reserves and liabilities, evaluate financial impact of programs, and participate in M&A and related financial analyses.

Serve as the liaison between the health plan and community organizations to design and execute outreach strategies, coordinate events, support members accessing services, build community partnerships, lead volunteer programs, represent the organization at health events, and manage logistics for field activities.

Design, build, test, and maintain scalable data solutions and ETL processes for health insurance reporting and analytics. Troubleshoot data issues, optimize Teradata/Greenplum databases, develop Power BI reports/dashboards, support Medicaid compliance reporting, and transition legacy processes to a Next Gen framework while partnering with business stakeholders.

Design, develop, test, and deploy Pega-based software solutions; analyze business and technical requirements; create detailed technical designs; integrate with MongoDB, GoLang, Java services, and Oracle; enforce code quality and unit testing, implement microservices, direct third-party developers, and support tier-3 incident management and application upgrades.

Audit medical records to identify inappropriate billing practices, investigate billing patterns, prepare findings, and recommend preventative measures. Requires clinical experience and coding expertise.

As an Account Executive II, you will represent Centene to clients, enhance client satisfaction, handle inquiries, and assist with renewals and negotiations, leveraging sales and marketing skills to build relationships.

Conduct comprehensive reviews of MS-DRG and APR-DRG coding and clinical documentation to ensure accuracy in DRG assignment and reimbursement, exercising professional judgment and collaborating with the Medical Director on complex cases.

The Vice President will direct provider network activities, lead provider network strategy, manage budget forecasts, and oversee contracting negotiations and analyses for Centene.

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.

Review prior authorization requests to determine medical necessity and appropriate level of care per regulatory guidelines. Communicate with providers and interdepartmental teams, escalate to Medical Directors as needed, document clinical information, assist with discharge/transfer authorization, and provide education and process improvement feedback to support timely, cost-effective member care.

Lead strategy, development, launch, and oversight of Managed Long-Term Services & Supports (MLTSS) and Duals product lines. Drive product extensions, ensure financial/quality/compliance performance, implement reporting and expansion plans, build relationships with CMS and state Medicaid, and institute continuous improvement. Requires ~20% travel.