Centene Corporation

Claims Specialist

• Ensure timely processing of 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 protocols and procedures
• Process first time claims
• Apply policy and provider contract provisions to determine if claim is payable
• Research and determine status of medical related claims
• Maintain records, files, and documentation as appropriate
• Meet and maintain department production and quality standards
• Successfully complete additional progressive claims training programs as required
• Performs other duties as assigned
• Complies with all policies and standards

Claims Analyst

Product Designer

• 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
• Executes the UX experiences that are clear and easy to understand
• Facilitates internal workshops and presentations for digital products regarding design thinking
• 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
• Collaborates with cross-functional teams and clients to define, design, deploy, and test user interface enhancements
• Creates deliverables that communicate proposed user experience designs effectively

UX Architect

Program Manager

• Identify opportunities to increase efficiency, improve service levels, and ensure regulatory and PA compliance through enhanced, standardized operations and governance practices
• Develop and execute strategies to realize PA improvement opportunities, ensuring enterprise‑level prioritization, clear decision rights, and appropriate resource alignment
• Manage multiple PA initiatives through the full project lifecycle
• Support structured PA governance cycles by ensuring initiatives are evaluated, prioritized, approved, and sequenced
• Utilize corporate and industry‑standard project management and governance tools to manage PA initiatives effectively
• Maintain detailed and accurate PA program documentation
• Compile, format, and validate review packets and governance decision materials for leadership review
• Coordinate and validate market, clinical, and SME inputs for PA governance materials
• Partner with analytics, medical economics, and operations teams to review financial and operational claims data
• Ensure ad‑hoc PA requests are logged, tracked, prioritized, and either executed or formally deferred
• Maintain a centralized PA documentation repository as the single source of truth for governance artifacts
• Provide strong leadership and communicate PA program and governance status to stakeholders
• Lead cross‑functional governance and working sessions to meet enterprise objectives and stakeholder expectations
• Negotiate with stakeholders to secure resources, resolve cross‑functional dependencies, and mitigate risks

Program Manager – PA Governance

Pharmacist

• receives and responds to calls from members, provider/physician's offices, and pharmacies
• makes outbound calls and enters pharmacy overrides into systems based on approved guidelines
• takes member/prescriber/pharmacist inquiry calls for benefit questions
• offers options including submission of a prior authorization request
• thoroughly researches issues and takes appropriate action to resolve them
• logs, tracks, resolves, and responds to all assigned inquiries and complaints
• maintains expert knowledge on all pharmacy benefits and formularies
• answers and conducts inbound and outbound calls with members and provider offices
• actively involved in the initiation and providing status for prior authorization/coverage determination
• identifies root cause issues to ensure enterprise solutions
• assists with special projects as assigned

Pharmacy Resolution Specialist

Compliance

• Reviews, interprets and summarizes proposed and enacted legislation and regulatory updates
• Monitoring proposed changes to Oregon Administrative Rules (OAR)
• Support the end-to-end process for the annual contract restatement
• Attend key meetings for Oregon Health Plan (OHP) contractor workgroups
• Support monthly Division of Financial Regulation (DFR) meetings

Regulatory Operations Analyst III – Medicaid

• Act as a subject matter expert and handles more complex pharmacy issues
• Respond to escalated calls from members, provider/physician's offices and pharmacies
• Make outbound calls and enter pharmacy overrides into systems based on approved guidelines
• Take member/prescriber/pharmacist inquiry calls for benefit questions including prior authorization requests
• Offer options including submission of a prior authorization request
• Thoroughly research issues and takes appropriate action to resolve them
• Assist team members often guiding them to the appropriate resolution of more complex inquiries
• Participate in training of less experienced staff
• Assist with audit preparation as needed

Senior Pharmacy Resolution Specialist

Systems Engineer

• 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 communicate these back to the business stakeholders
• Manages and tracks the status of requirements throughout the project lifecycle; enforce and redefine 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 review levels of IT services specified in the service-level agreements (SLAs) with the business
• Research, reviews, and analyzes the effectiveness and efficiency of existing requirement gathering processes and develop strategies for enhancing or further leveraging these processes; quantify potential efficiency opportunities and track accordingly
• Maintains system protocols by writing and updating procedures
• Provides references for users by writing and maintaining user documentation; provide help desk support; train 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

Senior Business Systems Analyst

• Ensure timely processing of complex pending medical claims
• Verify and update information on the submitted claims
• Review work processes to determine reimbursement eligibility
• Process first time claims with added complexity
• Communicate with stakeholders important information needed for successful processing
• Maintain appropriate records, files, documentation, etc.
• Meet and maintain department production and quality standards
• Performs other duties as assigned

Claims Analyst II

Analyst

• Analyzes and reviews the contact center's workload to build resourcing and optimize scheduling plans to meet business objectives and goals
• Analyzes the effectiveness and complex results of the contact center's schedule and provides scheduling methodology improvements
• Participates in and leads meetings with stakeholders to analyze staffing plans and performance
• Works closely with management and other stakeholders to understand staffing requirements
• Deploys analytical techniques to create optimized schedules that balances business needs with employee preferences
• Analyzes contact center patterns, including volumes, trends, and contact center productivities
• Mentors and supports other members of the workforce scheduling team
• Advises on using a centralized vs. decentralized queue strategy and evaluates how this strategy will impact key performance metrics
• Ensures accurate records of contact center staff schedules
• Influences changes in policies and procedures for the workforce management unit

Senior Workforce Scheduling Analyst

Medical Director

• 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

Designer

• 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

Senior Curriculum Designer

Manager

• Serve as the direct people leader for multiple teams responsible for Provider Enrollment, Auditing, and Provider Data Management & Updates.
• Manage, coach, and develop staff through performance management, training, and career development.
• Establish staffing models, productivity expectations, and cross ‑ functional alignment to support business and regulatory needs.
• Update and maintain training materials, policies, and standard operating procedures to ensure consistent execution across teams.
• Provide operational ownership and oversight of the health plan’s entire Provider Enrollment lifecycle , including initial enrollment, revalidation, updates, and terminations.
• Oversee provider enrollment auditing activities to ensure compliance with state, federal, NCQA, CMS, and contractual requirements.
• Provide oversight and governance of the Centene Corporate credentialing process , ensuring alignment, issue escalation, and audit readiness at the health plan level.
• Partner with internal and external stakeholders to resolve enrollment, credentialing, and data discrepancies.
• Ensure the timely and accurate processing of provider data updates (adds, changes, and terminations) across all systems.
• Develop and maintain data integrity through audits, controls, reporting, and root ‑ cause analysis.
• Establish and monitor KPIs and operational goals for Provider Enrollment and Provider Data Management functions.
• Manage encounter response files and error correction processes related to provider data.
• Lead provider data and enrollment audit preparation and execution, including internal, state, federal, and accreditation audits.
• Track audit findings, corrective action plans, and ongoing monitoring activities.
• Schedule and oversee monthly provider verifications related to enrollment specifications and demographic changes, particularly for designated specialty types.
• Responsible for systems implementation, enhancements, and process improvements related to provider enrollment and data management.
• Coordinate materials and provider data support for Requests for Applications (RFAs) , new business, and expansions.
• Collaborate with internal business partners to support enterprise initiatives and regulatory changes

Manager, Provider Data Management

Security Engineer

• Lead the Privacy & Security Enterprise Engagement Officers (EEO) Shared Services Team
• Collaborate with other Shared Services across the organization with a focus on EPSRM
• Support the Enterprise Engagement Officer team
• Build trusted partnerships with Health Plan leadership and key enterprise stakeholders
• Align staffing and resources to shared service and line of business complexity
• Ensure the team’s alignment with defined goals
• Direct and oversee the team’s ongoing efforts to serve as a subject-matter-expert for privacy, security and AI requirements
• Provide Executive-ready updates for Health Plan and EPSRM leadership
• Meet with regulators or other state representatives to answer questions
• Maintain a centralized requirements & deliverables register or pipeline mapping obligations to owners
• Ensure adequacy of control validation evidence

Director, Privacy & Security, Enterprise Engagement

• 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.

• Manages day to day operations of the Security Issues Management team
• Provides people leadership, workload prioritization, and operational oversight
• Ensures remediation efforts align with enterprise risk tolerance, regulatory expectations, and recognized cybersecurity frameworks
• Leads and oversees the end-to-end lifecycle of security issues management
• Partners with Internal Audit, Compliance, Legal, Privacy, Technology Risk, and technical teams to coordinate remediation activities
• Develops, matures, and continuously improves processes, documentation, and automation

Claims Analyst

UX Architect

Program Manager – PA Governance

Pharmacy Resolution Specialist

Regulatory Operations Analyst III – Medicaid

Senior Pharmacy Resolution Specialist

Senior Business Systems Analyst

Claims Analyst II

Senior Workforce Scheduling Analyst

Medical Director

Senior Curriculum Designer

Manager, Provider Data Management

Director, Privacy & Security, Enterprise Engagement

Medical Director

Manager, Security Issues Management