Jobs at Centene Corporation

Lead analytics for Internal Audit Claims: extract, transform, reconcile, and validate large claims datasets; build and maintain Power BI reports/dashboards; perform QA and tie-outs; support automation, bots/AI enablement, and executive reporting; mentor other analysts and partner with audit, IT, and business stakeholders to deliver repeatable, validated analytics.

Perform complex data analysis and predictive modeling for health management programs using financial, pharmacy, claims, provider, and member data. Cleanse and reconcile data, produce reports via Excel/Access/SQL, monitor trends, gather business requirements, update core systems, present findings to stakeholders, assist training junior analysts, and travel quarterly to Tampa, FL.

Perform detailed reviews of state and corporate payment policies for compliance, analyze coding, reimbursement and regulatory guidelines, develop and maintain payment policies and claims editing logic, support implementations through data analysis and testing, identify process improvements, and coordinate across business units.

Audit pharmacy prior authorization processes and data using MedPharm systems, identify process improvements, support clinical training, maintain audit records, and collaborate with business partners to resolve errors and present recommendations.

Develop and manage formularies across Commercial, Medicaid, Medicare Part D and other lines; review drugs and primary literature; analyze pharmacy cost and utilization trends; create clinical criteria, prior authorization guidelines, and adjudication edits; support P&T Committee processes and provide clinical guidance to pharmacy technicians.

Review psychological testing and treatment documentation for medical necessity and quality; authorize and monitor outpatient behavioral health and substance abuse care; conduct peer reviews; consult with providers and Medical Director; educate network practitioners on best practices and utilization management; respond to complaints and provide clinical oversight for outpatient services.

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.

Senior subject matter expert responsible for HEDIS quality oversight, leading NCQA audit workstreams, interpreting federal and state regulations, assessing and mitigating audit risks, supporting CMS submissions, developing enterprise standards and documentation, and partnering with health plans, auditors, IT, analytics, and quality stakeholders to ensure audit-defensible outcomes.

Manage a team ensuring audit quality and performance for payment integrity initiatives related to potentially preventable readmissions, overseeing compliance and program results.