Jobs at Centene Corporation

Coordinates statewide clinical appeals, fair hearings, and external reviews. Evaluates clinical information using recognized medical-necessity criteria, prepares case reviews and compliant response letters, maintains appeal files and logs, and collaborates with medical directors to clarify determinations. The role also coordinates fair hearings, follows up with members and providers, and maintains knowledge of NCQA and Oregon regulatory requirements.

Provide clinical data analysis, audits, and workflow recommendations to ensure compliance (HEDIS, URAC, NCQA). Design data pulls, produce analytical and audit reports, support corrective action plans, training, and regulatory audit preparation. Collaborate with clinical teams and data analysts to track performance, forecast staffing, and improve operational processes.

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.