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. Key Responsibilities - Review clinical authorization requests for medical necessity - Communicate with providers and build strong relationships - Partner with cross-functional teams - Complete 14 clinical reviews per day Schedule & Coverage - Monday–Friday, 8:30 a.m.–5:30 p.m. - Rotating weekends and holidays - Remote role, but candidate must reside in Oklahoma - No travel Skills for Success - Strong time management - Ability to meet production goals - Comfortable with technology - Clear, professional communication - Knowledge of Medicaid and utilization management preferred Position Purpose: Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care. - Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria - Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care - Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member - Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care - Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities - Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines - Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members - Provides feedback on opportunities to improve the authorization review process for members - Performs other duties as assigned - Complies with all policies and standards Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: - LPN - Licensed Practical Nurse - State Licensure required Pay Range: $27.02 - $48.55 per hour 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. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

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. *Qualified candidates must be able to work 2:00PM-10:30PM EST. The targeted start date for this role is 5/18/26* Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT. Position Purpose: The Senior Pharmacy Resolution Specialist will act as a subject matter expert and handles more complex pharmacy issues and respond to escalated calls from members, provider/physician's offices and pharmacies. This role will make outbound calls and enters pharmacy overrides into systems based on approved guidelines and approvals provided from clinical pharmacists. - Takes member/prescriber/pharmacist inquiry calls for benefit questions including prior authorization requests - Offers options including submission of a prior authorization request - Thoroughly researches issues and takes appropriate action to resolve them using the appropriate reference material within turnaround time requirements and quality standards - Answers and conducts inbound and outbound calls with members and provider offices to provide resolution to claims (i.e.: additional information requests and medication determination updates) - Thoroughly researches issues and takes appropriate action to resolve them within turnaround time requirements and quality standards - Assists team members often guiding them to the appropriate resolution of more complex and difficult inquiries - Participates in the training of less experienced staff, including opportunity for job shadowing - Acts as a liaison between internal departments on data gathering and problem solving while investigating problems of an unusual nature in the area of responsibility - Presents proposed solutions in a clear and concise manner - Assists with audit preparation as needed - Assists with miscellaneous special project work as assigned - Performs other duties as assigned - Complies with all policies and standards Education/Experience: High School Diploma / GED. 2 years of experience. Call center / customer service experience. Experience in healthcare environment (pharmacy operations, managed care, pharmacy hospitals and or pharmacy retail settings). License/Certification: Pharmacy technician certification preferred. Pay Range: $19.43 - $32.98 per hour 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. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development. Summary The Prior Authorization (PA) Pharmacist is responsible for reviewing prior authorization requests from providers to ensure safe and effective medication utilization. The PA Pharmacist will work with internal and external stakeholders to evaluate and continually develop strategies for Utilization Management. Essential Job Functions - Review prior authorization requests from medical professionals to ensure alignment with Preferred Drug List (PDL) criteria and current clinical guidelines. - Support peer-to-peer discussions with medical providers regarding prior authorization reviews. - Collaborate on the refinement of consultation scripting; solicit and utilize input from those contacted to improve scripting. - Contribute to the success of the Clinical Call Centers and Prior Authorization department by assisting with the implementation and management of both written and verbal communications to members and physicians. Serve as a resource for pharmacy-related questions and issues across the organization. - Contribute to program improvements by using continuous quality improvement processes, proactively identifying opportunities, and providing ongoing consultation and collaboration with product leaders. - Uphold the clinical integrity of pharmaceutical solutions by staying up to date on medication information and clinical guidelines, contributing to the identification of pharmacy program best practices, and collaborating with Medical Directors and Clinical Pharmacists to provide pharmacy expertise. - Collaborate internally with the pharmacy team (Pharmacy Manager, PDL Coordinator, Clinical Pharmacists) to identify trends or areas of opportunity, with the intent of identifying new drugs and therapeutic classes requiring utilization management. - Perform other duties as assigned. - Contribute creative solutions to improve the operational efficiency and effectiveness of the pharmacy team. Requirements - PharmD or B.S. in Pharmacy with relevant specialty background. - Registered Pharmacist with an unrestricted state license (Connecticut Pharmacist License preferred but not required). - Minimum of four (4) years of experience in clinical pharmacy. - Strong verbal and written communication skills. - Highly proficient in Microsoft Office products and ability to quickly learn proprietary systems. Basic Qualifications - Experience coordinating and collaborating with work teams preferred. - Ability to perform clinical reviews using relevant compendia and clinical trial data. - Managed care and/or prior authorization experience is a plus. - Strong research and implementation skills in practical settings. - Analytical skills that translate into practical and pragmatic recommendations. - Strong team orientation with respect for all members. - Strong interpersonal skills to support effective consultation and collaboration with internal and external stakeholders who do not directly report to this role. - Prior call center experience preferred. Work Environment - Work from home; reliable high-speed internet connectivity is required. - Expected working hours: 9:00 AM to 5:00 PM Eastern Time, including select holidays and occasional weekend on-call coverage. - A dedicated, private workspace (HIPAA-compliant) with high-speed internet access is required. Applications for this posting will be accepted until April 24, 2026. The pay range for this position is $90,900.00 - $129,900.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings. Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. Gainwell Technologies defines “wages” and “wage rates” to include “all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.

Are you passionate about improving the quality of healthcare? Are you ready to leverage your talents to make healthcare better for everyone? Do you want the opportunity to give back to your community? Do you want to have fun at work? Then join the growing team at Health Services Advisory Group (HSAG) that is transforming the delivery of healthcare in the United States! Description The Quality Improvement Specialist (QIS) plays a pivotal role in supporting nursing homes participating in the CMS Quality Improvement Network–Quality Improvement Organization (QIN-QIO) program. Responsibilities include conducting root cause analyses and developing customized action plans based on evidence-based interventions. The QIS collaborates closely with nursing home teams to support the effective use of Quality Assurance and Performance Improvement (QAPI) as the foundation for implementing strategies that drive measurable improvements in healthcare quality and resident safety. Acting as a trusted advisor, the QIS provides technical assistance, coaching, education, and training while fostering strong relationships with nursing home leaders. Key initiatives align with CMS priorities and address multiple areas of nursing home quality, such as: - Healthcare-associated infections - Readmissions - Falls with major injury - Antipsychotics - Pressure injuries - Adverse drug events - Vaccinations Core Competencies, Duties, and Responsibilities - Serve as the primary liaison for assigned nursing homes, building strong relationships and supporting participation in quality improvement initiatives. - Communicate complex healthcare concepts, quality improvement, and performance expectations clearly through meetings, written materials, and virtual engagements. - Apply evidence-based quality improvement methodologies (i.e., QAPI, PDSA) to co-design action plans with nursing homes that will improve quality and resident safety. - Provide tailored technical assistance, education, training, and QI coaching to nursing homes and stakeholders to support sustainable improvement. - Collaborate with internal teams and external partners to implement effective interventions and develop tools and resources. - Maintain current knowledge of quality improvement best practices and applicable regulatory requirements (e.g., CMS, CDC). - Manage multiple nursing homes as assigned, meeting established deadlines, demonstrating strong organizational skills, adaptability, accountability, and extended hours, on occasion. Education and Experience - Bachelor’s degree in healthcare related field required; master’s degree preferred. - Leadership experience in a nursing home setting preferred (e.g., Administrator, Director of Nursing, Infection Preventionist). - Minimum of 5 years working in or with nursing homes preferred. Other Qualifications - Strong written and verbal communication skills, including experience delivering presentations, conducting training, and engaging with providers via phone and email. - Detail-oriented with strong initiative, sound judgment, and the ability to manage multiple priorities independently. - Strong problem-solving skills - Ability to interpret and utilize data for quality improvement and resident safety initiatives. - Proficient in Microsoft Word, Excel and PowerPoint. $100,000 - $130,000 a year Work Environment The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Disclaimer This is not necessarily an exhaustive list of all responsibilities, skills, duties, requirements, efforts or working conditions associated with the position. While this is intended to be an accurate reflection of the current position, management reserves the right to revise the position or to require that other or different tasks be performed when circumstances change (e.g., emergencies, changes in personnel, work load, rush jobs requiring non-regular work hours, or technological developments). HSAG is an EEO Employer of Veterans protected under Section 4212. If you have special needs and require assistance completing our employment application process, please feel free to contact us. EOE M/F/Veteran/Disability