Jobs at Centene Corporation

Supports healthcare risk adjustment programs by coordinating cross-functional teams, managing program lifecycles, maintaining documentation, monitoring performance, translating reporting into actionable insights, and communicating status to stakeholders. The role facilitates requirements gathering, schedules, deliverables, process improvements, risk mitigation, compliance coordination, and provider and member engagement initiatives.

Reviews prior authorization requests for medical necessity, appropriateness, and benefit coverage. Coordinates with providers, medical directors, and internal teams; documents clinical information; supports transfers and discharge planning; educates stakeholders on utilization processes; and promotes compliant, high-quality, cost-effective care. Requires an active New York RN license, nursing education, and related clinical experience.

Performs concurrent utilization reviews to assess members’ health, medical necessity, acuity, resource use, length of stay, appropriate care settings, and discharge plans. Documents findings, collaborates with Medical Affairs, Medical Directors, providers, and care management, supports medical determinations, educates providers on utilization processes, and identifies opportunities to improve care appropriateness and medical necessity.

Leads complex healthcare quality improvement, regulatory, accreditation, and service improvement initiatives. Ensures compliance with state, federal, and accreditation standards; evaluates program outcomes; manages vendors; develops interventions to improve HEDIS, CAHPS, Star Ratings, HOS, and provider satisfaction. Prepares reports, communications, policies, audits, and committee materials while collaborating with providers, internal departments, external organizations, and senior leadership.

Manages the development, review, and approval of HEDIS provider toolkits and member and provider communications. Creates accessible, readable, translated health-related materials; coordinates with vendors, business partners, compliance, marketing, health plans, and regulatory stakeholders; tracks recommendations and approvals; and maintains communications processes in a managed care environment.

Designs, implements, evaluates, and maintains corporate training resources for Quality and operational teams. Creates instructional materials, e-learning content, assessments, training plans, and support sites; reviews and updates curriculum based on learning and quality outcomes; and facilitates training as needed. Requires proficiency in Articulate Storyline and knowledge of adult learning principles and instructional design methodologies.

Coordinates statewide clinical appeals, fair hearings, and external reviews for members and providers. Reviews clinical information against nationally recognized medical-necessity criteria, prepares case reviews and compliant response letters, maintains appeal records, analyzes follow-up information, and coordinates with medical directors, internal departments, and external agencies. Ensures compliance with state regulations and NCQA standards.

Apply cash receipts and payments in company systems, enter manual billing information, maintain Accounts Payable check request logs, analyze accounts receivable and financial reports, and assist with semi-monthly billing. Requires accounting or finance experience, medical cash posting experience, and advanced Microsoft Excel and Word skills.

Apply cash receipts and payments across systems, enter billing information, maintain accounts payable check request logs, analyze accounts receivable and cash-flow reports, and support semi-monthly billing. Requires a high school diploma, at least two years of accounting, accounts receivable, or accounts payable experience, one year of medical cash or line-item posting experience, and advanced Microsoft Excel and Word skills.

Develops and manages strategic provider relationships supporting value-based and risk-based care programs. Advises providers and internal teams on program design, performance metrics, reporting, contracts, payment methodologies, and operational processes. Analyzes quality, cost, and utilization data; presents recommendations to executives; leads performance improvement initiatives; resolves provider issues; supports contracting strategy; delivers training; and promotes process efficiencies across provider networks.

Oversee healthcare operations and business strategy across cross-functional teams. Develop performance-tracking methodologies, analyze data and return on investment, improve processes, and support strategic initiatives. Identify opportunities to reduce costs, eliminate waste, improve quality, and increase staff, provider, and member satisfaction. Serve as an internal advisor on operational improvement activities and manage data-driven solutions for clients.

Leads operational strategy, process improvement, and execution across shared services supporting Medicare and Duals managed care products. Serves as a liaison among product leadership, shared services, markets, and corporate partners; establishes KPIs and operating procedures; oversees integration, due diligence, operational readiness, risk mitigation, and performance optimization. Requires expertise in managed care operations, government contracting, regulatory compliance, and cross-functional project coordination.

Leads enterprise transformational change management and communications across strategic initiatives. Develops change strategies, stakeholder engagement, leadership alignment, training, organizational readiness, adoption, and sustained implementation. Partners with project teams, HR, culture teams, and business leaders to drive leadership development, collaboration, employee adoption, and effective execution. Maintains transformation center-of-excellence methodologies and best practices.

Reviews non-formulary medication prior authorization requests for clinical appropriateness, verifying eligibility, benefits, claims, chart notes, laboratory values, and policy criteria. Applies clinical judgment, communicates with physicians and pharmacy staff, researches drug information, develops criteria, supports formulary decisions, and compiles utilization and audit reports. Provides periodic weekend and holiday coverage.

Analyze claims, provider, member, and encounter data to measure network and contract changes, validate savings, identify trends and data irregularities, and support healthcare cost and outcome improvements. Develop and troubleshoot SQL and analytics reports, perform root-cause analysis, automate processes, communicate insights to stakeholders, manage large-scale initiatives, and provide technical guidance to junior analysts.

Manage provider enrollment and data updates within healthcare systems. Review and validate provider claims-payment and directory information, perform quality checks, research discrepancies, resolve system issues, and ensure provider data is complete and accurate according to plan specifications and business rules.

Supervises utilization management nurses conducting prior authorization, concurrent, and retrospective reviews. Oversees performance, compliance, quality, staffing, coaching, onboarding, and training while resolving complex member care issues. Develops and implements utilization management policies, supports regulatory compliance, promotes process improvements, and coordinates communication among team members, members, providers, and senior management.

Assists with financial management and reporting for health plans, including monthly analyses, statutory reports, reconciliations, audits, internal controls, and business analysis. Monitors accounting processes for GAAP and SSAP compliance, supports process improvements, and coordinates health plan needs across Finance and operational teams. Leads and mentors two direct reports while using advanced Excel, Power Query, Power Automate, and AI tools to improve efficiency.

Analyzes and resolves provider claims, authorization appeals, and member grievances. Prepares response letters, maintains appeal and grievance files, and may coordinate committee activities. Supports pay-for-performance and HEDIS programs through data entry, provider outreach, claims research, and information tracking. Manages high volumes of documents and incoming mail while complying with organizational policies and standards.

Provides consultative support to healthcare providers by analyzing performance, member engagement, quality, utilization, cost, and risk data. Develops reports and presentations, facilitates performance improvement discussions, educates providers on value-based performance tools, and presents Health Benefits Ratio analyses for operating committee meetings. Requires collaboration with health plan quality teams and provider reimbursement expertise.