Centene Corporation

Nurse

• Complete timely inpatient utilization reviews against medical necessity criteria, health plan policies, and applicable standards
• Review clinical records and document decisions accurately
• Refer appropriate cases for medical director review
• Work with providers, facilities, and internal teams to coordinate care and support discharge planning
• Assist with quality reviews, audits, and compliance activities
• Manage daily case volume while meeting quality, turnaround time, and productivity expectations
• Share clinical expertise with teammates and raise recurring issues or improvement opportunities to leadership
• Perform concurrent reviews to determine members’ overall health, appropriate care, and level of care
• Review acuity level, resource consumption, length of stay, quality, continuity of care, and discharge planning
• Work with Medical Affairs and/or Medical Directors regarding member care
• Collect, document, and maintain concurrent review findings, discharge plans, and actions in health management systems
• Work with healthcare providers to approve medical determinations or provide recommendations
• Educate providers on utilization processes
• Provide leadership feedback on opportunities to improve appropriate care levels and medical necessity
• Review transfer and discharge plans to support timely transitions
• Collaborate with care management on member referrals
• Perform other duties as assigned

Clinical Review Nurse – Concurrent Review

Account Manager

• Maintain partnerships between the health plan and contracted provider networks
• Build client relations to support the highest level of care for members
• Engage providers to align on network performance opportunities and solutions
• Provide consultative account management and accountability for issue resolution
• Drive performance in contract incentive performance, quality, and cost utilization
• Serve as the primary provider contact and liaison with the health plan
• Triage provider issues to internal partners for resolution
• Respond to external provider-related issues
• Investigate, resolve, and communicate provider claim issues and changes
• Enter provider-related demographic information changes
• Educate providers on referrals, claims submission, website usage, EDI solicitation, and related topics
• Conduct provider orientations and ongoing education
• Write and update orientation materials
• Manage network performance for an assigned territory
• Evaluate provider performance and develop strategic improvement plans
• Drive improvements in Risk/P4Q, HBR, HEDIS/quality, cost, and utilization
• Complete special projects and other assigned duties
• Comply with all policies and standards

Provider Engagement Account Manager

Manager

• Develop, assess, and facilitate complex care management activities for members with primarily physical needs
• Evaluate member needs, access barriers, and social determinants of health
• Develop ongoing care/service plans and collaborate with providers, specialists, and community resources
• Identify care problems and barriers and provide care management interventions
• Coordinate between members, families/caregivers, and care provider teams
• Monitor member status, condition changes, and progress toward care plan goals; revise plans as needed
• Provide resource support for employment, housing, participant direction, independent living, justice, and foster care services
• Facilitate timely access to needed care and services
• Conduct telephonic, digital, home, and other site outreach
• Collect, document, and maintain member information and care management activities for regulatory compliance
• Educate members and families/caregivers on disease processes, care gaps, provider instructions, care options, referrals, and healthcare benefits
• Provide leadership feedback on opportunities to improve care quality and cost-effectiveness
• Perform other assigned duties and comply with policies and standards

Care Manager, RN

Analyst

• Perform business impact analyses of Centene’s business units to identify and document risks for business disruption
• Conduct interviews and analyze potential business disruptions, risks, and single points of failure
• Develop and refresh business continuity/recovery plans
• Build and maintain relationships with key business representatives
• Conduct incident response exercises with business units
• Review plan gaps, document lessons learned, and follow up until resolved
• Track program metrics to show activities and progress
• Assist with configuring and maintaining business continuity and crisis management tools
• Document and improve project management processes, SOPs, and team efficiency
• Provide response coordination and communications support during business disruptions

Business Continuity Analyst II

• Develop, assess, and facilitate complex care management activities for primarily physical needs members
• Provide high-quality, cost-effective healthcare outcomes through personalized care plans and education
• Evaluate member needs, barriers to care, and social determinants of health
• Develop ongoing care plans and collaborate with providers, specialists, and community resources
• Identify problems and barriers to care and provide appropriate interventions
• Coordinate person-centered care among members, families, caregivers, and provider teams
• Monitor member status, changes in condition, and progress toward care plan goals
• Provide resource support for employment, housing, participant direction, independent living, justice, and foster care services
• Facilitate timely access to needed care and services
• Conduct telephonic, digital, home, and other site outreach
• Collect, document, and maintain member information and care management activities for regulatory compliance
• Educate members and families/caregivers on disease processes, care gaps, provider instructions, care options, referrals, and healthcare benefits
• Provide leadership feedback on opportunities to improve care quality and cost-effectiveness
• Perform other assigned duties and comply with policies and standards

• Maintain partnerships between the health plan and contracted provider networks
• Build client relations to ensure delivery of the highest level of care to members
• Engage providers on network performance opportunities and solutions
• Manage consultative account management and accountability for issue resolution
• Drive contract incentive performance, quality, and cost utilization
• Serve as primary contact and liaison between providers and the health plan
• Triage provider issues to internal partners for resolution
• Respond to external provider-related issues
• Investigate, resolve, and communicate provider claim issues and changes
• Enter provider-related demographic information changes
• Educate providers on referrals, claims submission, website usage, EDI solicitation, and related topics
• Conduct provider orientations and ongoing provider education
• Manage network performance for assigned territory
• Evaluate provider performance and develop strategic improvement plans
• Drive improvements in Risk/P4Q, HBR, HEDIS/quality, cost, and utilization
• Complete special projects as assigned
• Conduct regular in-person physician visits for real-time support and performance discussions
• Use data analytics to monitor provider performance and provide actionable feedback

Investigator

• Conduct fraud, waste, and abuse investigations using referrals, claims data, medical records, interviews, data analytics, and other investigative resources
• Analyze, document, and maintain investigative activities, findings, recommendations, and outcomes
• Review claims, medical records, provider billing practices, enrollment information, financial records, and other documentation
• Prepare investigative reports, case summaries, referrals, and supporting documentation
• Collaborate with internal business partners, compliance, legal, provider and payment integrity teams, and external agencies
• Support audits, overpayment identification and recovery efforts, regulatory responses, special projects, and program integrity initiatives
• Monitor emerging fraud schemes, billing irregularities, and trends and recommend appropriate actions
• Support case progression through onsite audits, visits, drive-by activities, and interviews
• Perform other duties as assigned and comply with all policies and standards

SIU Investigator

Operations

• Lead and manage No Surprises Act Independent Dispute Resolution operations
• Ensure timely, accurate, and compliant handling of federal and state dispute resolution activities
• Oversee end-to-end IDR case administration, including dispute initiation, review, submission, determination, payment resolution, and case closure
• Manage inventory, productivity, quality, service levels, and regulatory timelines in a high-volume environment
• Lead, develop, and manage staff and contracted resources
• Conduct workforce planning, coaching, performance management, and resource allocation
• Monitor and analyze operational and financial performance metrics
• Identify trends, risks, and opportunities to improve outcomes and efficiency
• Maintain controls, documentation standards, policies, and audit readiness
• Manage arbitration-related fees, payment determinations, reconciliations, and financial exposure tracking
• Collaborate with Legal, Compliance, Regulatory Affairs, Claims, Provider Operations, Finance, and other stakeholders
• Lead regulatory implementations, workflow enhancements, system changes, training efforts, and process improvement initiatives
• Present operational updates, performance results, risks, and recommendations to leadership and cross-functional partners
• Perform other duties as assigned
• Comply with all policies and standards

Manager, Independent Dispute Resolutions Operations

• Perform concurrent reviews to determine members’ overall health, appropriate care, and level of care
• Review acuity level, resource consumption, length of stay, and discharge planning
• Work with Medical Affairs and/or Medical Directors regarding member care
• Collect, document, and maintain concurrent review findings, discharge plans, and actions in health management systems
• Work with healthcare providers to approve medical determinations or provide recommendations
• Educate providers on utilization processes
• Provide leadership feedback on opportunities to improve level of care and medical necessity
• Review transfer and discharge plans to ensure timely transitions between levels of care and facilities
• Collaborate with care management on member referrals
• Comply with all policies and standards
• Perform other duties as assigned

Data Analyst

• Analyze integrated and extensive datasets to extract value and influence business decisions
• Collaborate with business stakeholders to identify value, develop solutions, and deliver insights that reduce cost of care and improve clinical outcomes
• Interpret and analyze claims, provider, member, and encounters data
• Identify and assess the business impact of trends
• Develop, maintain, and troubleshoot complex scripts and reports using SQL, Microsoft Excel, and other analytics tools
• Contribute to planning and execution of large-scale projects with limited direction
• Assist in designing, testing, and implementing process enhancements and automation opportunities
• Perform root-cause analysis of data irregularities and present findings and solutions to leadership and customers
• Manage multiple data review processes and tasks within targeted timelines
• Apply quantitative analysis, data mining, and data presentation expertise
• Partner cross-functionally and communicate findings to non-technical business partners
• Engage customers and business partners to gather requirements and validate results
• Present data-driven insights and recommendations to internal and external stakeholders
• Provide technical guidance to junior analysts

Data Analyst III – Healthcare Analytics

Director

• Coordinate state government relations and legislation for the Department of State Government Relations
• Assist the Department of Legislative and Regulatory Compliance and Corporate Compliance in ensuring compliance with federal laws
• Lobby state legislatures and state agencies on behalf of the company
• Set or recommend legislative priorities and develop public policy positions
• Analyze and review state regulatory and legislative proposals
• Recommend and prepare company positions, including testimony before legislative bodies
• Determine operational impact evaluations as necessary
• Coordinate lobbying activities
• Communicate legislative and regulatory changes
• Recommend initiatives to improve financial performance
• Serve as liaison/representative to state and national health plan associations
• Prepare and present reports to the Board of Directors as assigned
• Assist in compliance with state laws
• Perform other duties as assigned
• Comply with all policies and standards

Director, Government Affairs

Program Manager

• Coordinate implementation of new regulatory requirements, including the REAL Health Providers Act, Medicaid Mega Rule, state-specific directory regulations, and ongoing compliance reporting activities such as RARR
• Serve as a key liaison for tracking regulatory changes, assessing business impact, and driving remediation efforts across multiple teams
• Create and present executive-level communications for program updates and cross-functional executive-level discussion
• Lead large-scale, cross-functional implementation or process-improvement projects
• Coordinate with organizational leaders on restructuring and realignment of team members
• Oversee program planning, management, and execution, including scope, schedule, and budget
• Create comprehensive timelines and ensure appropriate deliverables follow project management standards
• Coordinate project managers and business analysts managing individual workgroups
• Create executive dashboards and project-status updates
• Develop reports for ongoing analytics after project implementation
• Deliver best-practice and training information to indirect reports, peers, and employees
• Prepare and deliver documents for Program Steering Committees and the Executive team
• Assess program risks, escalate issues, and develop risk mitigation plans
• Manage risk, budget/forecast, dependencies, and strategic analysis of business or operational opportunities
• Serve as the first escalation point for project issues and risks
• Communicate business and technology issues and solutions

Program Manager IV

Network Engineer

• Assure providers are set up accurately in the provider information system for state reporting, claims payment, and directories
• Manage state deliverables, network reporting, directories, and claims payment resolution related to provider setup
• Support external provider representatives in resolving provider data issues
• Research and respond to provider-related issues
• Act as internal and external liaison for provider networking
• Maintain relationships with participating physicians, physician groups, multi-specialty groups, and ancillary providers
• Act as account manager and gatekeeper for assigned groups
• Administer contractual provider relationships and maintain accurate provider databases
• Provide training, education, and information to providers
• Research, analyze, and resolve complex contract, claims, eligibility, appeals, grievance, and provider data issues
• Serve as primary liaison between assigned providers and the health plan
• Act as department subject matter expert
• Perform other duties as assigned and comply with policies and standards

Senior Provider Engagement Network Specialist

Pharmacist

• Define and develop standard and custom formularies for Commercial, Medicaid, Medicare Part D, and Health Information Marketplace lines of business
• Develop drug product reviews and formulary recommendations by assessing drug use trends, new drug releases, and primary literature
• Analyze pharmacy cost of care and trends, and coordinate appropriate-use protocols and guidelines
• Set criteria for medication analysis and coordinate client reports
• Meet regulatory reporting requirements for drug utilization review and fraud and abuse reporting
• Develop clinical criteria for non-formulary or non-preferred drug list medications and communicate recommendations to clients
• Develop and design clinical edits to adjudicate claims and enhance drug utilization
• Develop and review prior authorization and non-formulary guideline criteria supporting Pharmacy and Therapeutics Committee functions and pharmacy benefit design
• Research drug information for prior authorization reviews
• Provide clinical guidance and support to assigned pharmacy technicians
• Prepare support documentation and communications for Pharmacy & Therapeutics Committee reviews and decisions
• Perform other duties as assigned
• Comply with all policies and standards

Clinical Formulary Pharmacist

• Perform concurrent reviews to determine members’ overall health, appropriate care, medical necessity, and level of care
• Review acuity level, resource consumption, length of stay, quality and continuity of care, and discharge planning
• Work with Medical Affairs and Medical Directors regarding member care
• Document and maintain review findings, discharge plans, and actions in health management systems
• Work with healthcare providers to approve medical determinations or provide recommendations
• Educate providers on utilization processes
• Provide leadership feedback on appropriate level of care and medical necessity
• Review transfer and discharge plans for timely transitions between levels of care and facilities
• Collaborate with care management on member referrals
• Comply with policies and standards and perform other assigned duties