Centene Corporation

Role Description You could be the one who changes everything for our 28 million members by using technology to improve health outcomes around the world. As a diversified, national organization, Centene's technology professionals have access to competitive benefits including a fresh perspective on workplace flexibility. - Drives the collaboration with business and IT stakeholders to translate complex business requirements into comprehensive functional and non-functional technical specifications, ensuring alignment with strategic goals and solution design. - Gathers and validates business/technology requirements to establish scope and parameters of requirements and define project impact, outcome criteria, and metrics. - Analyzes and verifies requirements for completeness, consistency, comprehensibility, feasibility, and conformity to standards. - Translates conceptual user requirements into functional requirements in a clear manner that is comprehensible to developers/project team. - Creates systems and business process models, specifications, diagrams, and charts to provide direction to developers and/or the project team. - Interprets user requirements into feasible options and communicates these back to the business stakeholders. - Manages and tracks the status of requirements throughout the project lifecycle; enforces and redefines as necessary. - Communicates changes, enhancements, and modifications of business requirements to project managers, sponsors, and other stakeholders so that issues and solutions are understood. - Plans and coordinates user acceptance testing (UAT). - Monitors and reviews levels of IT services specified in the service-level agreements (SLAs) with the business. - Researches, reviews, and analyzes the effectiveness and efficiency of existing requirement gathering processes and develops strategies for enhancing or further leveraging these processes; quantifies potential efficiency opportunities and tracks accordingly. - Maintains system protocols by writing and updating procedures. - Provides references for users by writing and maintaining user documentation; provides help desk support; trains users. - Prepares technical reports by collecting, analyzing, and summarizing information and trends. - Involved in clarifying requirements and implementing solutions that meet the business needs. - Documents business requirements and potential solutions for system functionality and reporting needs. - Performs other duties as assigned. - Complies with all policies and standards. Qualifications - A Bachelor's degree in a quantitative or business field (e.g., statistics, mathematics, engineering, computer science). - 4 – 6 years of related experience or equivalent experience acquired through accomplishments of applicable knowledge, duties, scope, and skill reflective of the level of this position. Requirements - Experience with Data Processing, Data Analysis, reporting, data extract to flat files, data ingestion from flat files with different delimiters using Python/SQL/Power BI. - Knowledge of Python, SQL, and Power BI. - Knowledge of Snowflake, Teradata, and/or any other RDBMS. - Knowledge of health care payer business functions and operations. - Knowledge of Agile Software Development; Software Development Life Cycle. Soft Skills - Seeks to acquire knowledge in area of specialty. - Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions. - Ability to work independently. - Demonstrated analytical skills. - Demonstrated project management skills. - Demonstrates a high level of accuracy, even under pressure. - Demonstrates excellent judgment and decision-making skills. Benefits - Competitive pay. - Health insurance. - 401K and stock purchase plans. - Tuition reimbursement. - Paid time off plus holidays. - A flexible approach to work with remote, hybrid, field, or office work schedules. - Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. - Total compensation may also include additional forms of incentives. - Benefits may be subject to program eligibility. Company Description Centene is an equal opportunity employer that is committed to diversity and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.

Role Description You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. This role is remote for candidates located in the State of Oregon only with some potential travel to our Salem office. - Reviews, interprets and summarizes proposed and enacted legislation and regulatory updates to the business as a subject matter expert on various complex topics. - Monitoring OAR Changes: - Tracking proposed changes to Oregon Administrative Rules (OAR). - Keeping subject matter experts (SMEs) updated and collecting feedback throughout the process. - Engaging in Rule Advisory Committees (RACs). - Supporting the submission of written feedback to the Oregon Health Authority (OHA). - Acting as the business owner for the RLI (Regulatory Legislation Implementation) process. - Annual Contract Restatement: - Supporting the end-to-end process for the annual contract restatement. - Monitoring all changes from the initial proposal through contract finalization and implementation. - Attending related meetings and collaborating with the project manager to track implementation status. - Identifying and escalating risks to the Executive Sponsor. - Analyzing contract amendments as they occur throughout the year. - OHP Contractor Workgroups: - Attending key meetings and sharing topics in advance. - Distributing information afterward. - Responding to Requests for Information (RFIs) resulting from these meetings. - Bringing SMEs together as needed to discuss pertinent topics. - DFR Meetings: - Supporting monthly Division of Financial Regulation (DFR) meetings by attending and organizing follow-ups. - Acting as the primary contact for rules, bulletins, and expectations. - Managing communications and ensuring compliance with regulatory requirements. - Performs other duties as assigned. - Complies with all policies and standards. Qualifications - Demonstrated ability to build and maintain effective working relationships with state regulators, particularly the Oregon Health Authority (OHA). - Strong technical understanding of Medicaid policy, administrative rules, and regulatory guidance; prior experience working at or with OHA is a plus. - High level of attention to detail and strong organizational skills to manage complex regulatory requirements and timelines. - Ability to translate highly technical regulatory and policy language into clear, plain-language guidance and actionable recommendations for internal collaborators. - Proven ability to thoughtfully and effectively advocate for regulatory clarifications or changes when appropriate. - Strong compliance mindset, with experience ensuring organizational practices align with regulatory and contractual requirements. Requirements - Bachelor's degree in business, Communications, Healthcare, Political Science/Pre-Law or equivalent experience required. - Master's Degree in a related field, Juris Doctorate degree may be considered in place of experience preferred. - 4+ years experience in health insurance, legal, compliance or related field required. - Experience reviewing regulations and providing interpretation using terms appropriate for the audience preferred. - Experience in commercial health insurance and/or behavioral health managed care preferred. Benefits - Competitive pay. - Health insurance. - 401K and stock purchase plans. - Tuition reimbursement. - Paid time off plus holidays. - Flexible approach to work with remote, hybrid, field or office work schedules.

Role Description You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. - Ensure timely processing of complex pending medical claims. - Verify and update information on the submitted claims. - Review work processes to determine reimbursement eligibility. - Ensure payments and/or denials are made in accordance with company practices and procedures. - Process first time claims with added complexity. - Apply policy and provider contract provisions to determine if claim is payable, if additional information is needed, or if claim should be denied. - Research and determine status of medical related claims. - Resolve claims related to adjustments, provider calls, reconsiderations and appeals. - Communicate with stakeholders’ important information needed for the successful processing of claims with added complexity. - Maintain appropriate records, files, documentation, etc. - Meet and maintain department production and quality standards. - Performs other duties as assigned. - Complies with all policies and standards. Qualifications - High school diploma or equivalent required; Associate degree or equivalent experience preferred. - 2+ years of health insurance or claims related experience required. - Intermediate PC and Microsoft Office skills; basic math proficiency required. - Medical coding knowledge (ICD 9/10, CPT, HCPCS) and public program claims experience preferred. - Experience with Medicaid, Marketplace, or Medicare claims preferred. - Required to successfully complete claims basic training, COB advanced training, and ramp period. Requirements - For Centene Dental & Vision Services: - Claims refers to dental and/or vision claims. Experience in processing Dental or Vision claims preferred. - Working knowledge of ICD-9/10, CDT and dental terminology preferred. - Experience with Medicaid or Medicare claims preferred. - For External Candidates: - 3+ years of health insurance industry experience, including claims processing, physician office, or related administrative experience required. - Experience with Amisys or Facets preferred. - Required to successfully complete claims basic training, COB advanced training, and ramp period. Benefits - Competitive pay. - Health insurance. - 401K and stock purchase plans. - Tuition reimbursement. - Paid time off plus holidays. - Flexible approach to work with remote, hybrid, field or office work schedules. - Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. - Total compensation may also include additional forms of incentives. - Benefits may be subject to program eligibility.

Role Description You could be the one who changes everything for our 28 million members by using technology to improve health outcomes around the world. As a diversified, national organization, Centene's technology professionals have access to competitive benefits including a fresh perspective on workplace flexibility. - Executes the structure and flow of a digital solution (website, app, software, mobile, etc.). - Maps how the end-user interacts with the product and develops a structure, including layouts and flows, that ensure features and content are organized in a logical, intuitive, and complimentary way. - Executes UX experiences that are clear and easy to understand while leveraging a complex, data-heavy experience. - Facilitates internal workshops and presentations for digital products regarding design thinking, leadership strategy, and the work of design teams. - Outlines and researches user industry-wide information to uncover insights and improve the effectiveness of our products. - Implements design concepts and experiences for websites. - Coaches Product Designers on design experience methodologies and approaches. - Analyzes current and potential websites to provide actionable recommendations based on user experience best practices. - Collaborates with cross-functional teams and clients to define, design, deploy, and test user interface enhancements and technical solutions which meet the needs of the company, its clients, and the end users. - Creates deliverables that communicate proposed user experience designs effectively. - Performs other duties as assigned. - Complies with all policies and standards. Qualifications - A Bachelor's degree in a quantitative or business field (e.g., statistics, mathematics, engineering, computer science) and requires 2 – 4 years of related experience. - Or equivalent experience acquired through accomplishments of applicable knowledge, duties, scope and skill reflective of the level of this position. Requirements - One or more of the following skills are desired: - Experience with Adobe Acrobat; Digital Design; User Experience. - Experience with Journey Mapping; Sitemaps; User Flows; Wireframing. - Intermediate - Seeks to acquire knowledge in area of specialty. - Intermediate - Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions. - Intermediate - Ability to work independently. Benefits - Centene offers a comprehensive benefits package including: - Competitive pay. - Health insurance. - 401K and stock purchase plans. - Tuition reimbursement. - Paid time off plus holidays. - A flexible approach to work with remote, hybrid, field, or office work schedules. - Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. - Total compensation may also include additional forms of incentives. - Benefits may be subject to program eligibility.

Role Description The Guardianship Liaison supports members who are under state-appointed adult guardianship. This role serves as the primary liaison between the state guardianship department, the interdisciplinary care team, and service providers to ensure coordination and delivery of medically necessary services in alignment with the state-approved service plan. The Guardianship Liaison is responsible for: - Facilitating enrollment into care management. - Integrating the state-approved service plan into the member's individualized care plan. - Ensuring coordination of physical health, behavioral health, and health-related social needs (HRSN). - Supporting continuity of care, regulatory compliance, and improved member outcomes through proactive engagement, collaboration, and care plan oversight. Key responsibilities include: - Conducting outreach to state-appointed guardians to obtain and review state-approved service plans, ensuring alignment with care management requirements and identification of member needs. - Functioning as a liaison and advocate between the member, state guardian, providers, and community-based organizations to support coordination of services and access to care. - Completing comprehensive assessments and developing individualized, person-centered care plans that incorporate medical, behavioral health, and social determinants of health needs. - Collaborating with the interdisciplinary care team, including providers and community resources, to implement, monitor, and adjust care plans based on member needs and outcomes. - Facilitating care team meetings, as appropriate, to review progress toward goals, update care plans, and ensure alignment with the state-approved service plan. - Monitoring care plan implementation and member progress, identifying barriers to care and coordinating interventions to support goal attainment. - Assisting members and guardians with accessing benefits and community resources, particularly when existing benefits are exhausted or unavailable, to address unmet needs. - Monitoring and evaluating care plan implementation, utilization, and member outcomes to ensure effective care management, support regulatory reporting, and drive quality improvement. - Collecting and documenting all member information to ensure compliance with current state, federal, and third-party payer regulations and contractual requirements. - Performing other duties as assigned. - Complying with all policies and standards. Qualifications - Master's degree in behavioral health or social work, or a degree from an accredited school of nursing. - 2 – 4 years of related experience; guardianship experience preferred. Requirements - One of the following is required: Licensed Master's Behavioral Health Professional (e.g., CSW, LCSW, LMSW, LPCC, LPC) or RN based on state contract requirements with behavioral health experience required. Benefits - Competitive pay. - Health insurance. - 401K and stock purchase plans. - Tuition reimbursement. - Paid time off plus holidays. - Flexible approach to work with remote, hybrid, field, or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Company Description Centene is an equal opportunity employer that is committed to diversity and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.

• Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit • Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities • Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making • Supports effective implementation of performance improvement initiatives for capitated providers • Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members • Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements • Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership • Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes • Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals • Participates in provider network development and new market expansion as appropriate • Assists in the development and implementation of physician education with respect to clinical issues and policies • Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components • Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care • Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality • Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment • Develops alliances with the provider community through the development and implementation of the medical management programs • Represents the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues • Represents the business unit at appropriate state committees and other ad hoc committees • May be required to work weekends and holidays in support of business operations, as needed

• Design and implement instructional strategies that support learning and performance within functional teams • Lead meetings with stakeholders to understand business requirements, develop learning strategies to meet said requirements and lead development processes • Create and implement learning, virtual simulations and assessments on approved platforms in online environment • Outline and deliver timely training project plans • Oversee maintenance of training resources and support sites • Develop instruments to assess individual change in knowledge, skills and quality results • Conduct reviews of training program objectives assessing the need for modifications to content and structure • Research current industry trends, recommend and incorporate related updates into the standard curriculum • Facilitate training as needed to support operational goals

Title: Supervisor, Utilization Management Location: Remote-NY Full time Job Description: You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Work Schedule & Requirements - This is a fully remote position operating on an Eastern Standard Time (EST) schedule, Monday through Friday, 8:30 AM – 5:00 PM. - Active New York State Registered Nurse (NYS RN) licensure is required at the time of application to be considered for this role. Position Purpose: Supervises Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members. Supervises day-to-day activities of utilization management team. - Monitors and tracks UM resources to ensure adherence to performance, compliance, quality, and efficiency standards - Collaborates with utilization management team to resolve complex care member issues - Maintains knowledge of regulations, accreditation standards, and industry best practices related to utilization management - Works with utilization management team and senior management to identify opportunities for process and quality improvements within utilization management - Educates and provides resources for utilization management team on key initiatives and to facilitate on-going communication between utilization management team, members, and providers - Monitors prior authorization, concurrent review, and/or retrospective clinical review nurses and ensures compliance with applicable guidelines, policies, and procedures - Works with the senior management to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services - Evaluates utilization management team performance and provides feedback regarding performance, goals, and career milestones - Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards - Assists with onboarding, hiring, and training utilization management team members - Leads and champions change within scope of responsibility - Performs other duties as assigned - Complies with all policies and standards Education/Experience: Requires graduation from an Accredited School of Nursing or Bachelor's degree and 4+ years of related experience. Knowledge of utilization management principles preferred. License/Certification: - RN - Registered Nurse - State Licensure and/or Compact State Licensure required - Active New York State Registered Nurse (NYS RN) licensure is required at the time of application to be considered for this role. Pay Range: $75,300.00 - $135,400.00 per year Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

• Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit • Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities • Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services • Supports effective implementation of performance improvement initiatives for capitated providers • Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members • Conduct regular rounds to assess and coordinate care for high-risk patients • Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals • Participates in provider network development and new market expansion as appropriate. • Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.

• Analyze integrated and extensive datasets to extract value, impacting business decisions • Work collaboratively with key business stakeholders to identify areas of value, develop solutions, and deliver insights to reduce overall cost of care for members and improve clinical outcomes • Focus on enterprise provider analytics to measure and report the actual impact of contract and network changes against projected outcomes • Deliver standardized, structured reporting to track implementation accuracy and validate savings • Interpret and analyze data from multiple sources including 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, or other analytics tools • Contribute to planning and execution of large-scale projects with limited direction from leadership • Assist in the design, testing, and implementation of process enhancements and identify opportunities for automation • Identify and perform root-cause analysis of data irregularities and present findings to leadership and/or customers • Manage multiple, variable tasks and data review processes with limited supervision within targeted timelines • Demonstrate a sense of ownership over projects and ask probing questions to understand the business value of tasks • Communicate and present data-driven insights and recommendations to stakeholders