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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.

*Applicants for this job have the flexibility to work remote from home anywhere in the United States.

**Position Purpose:** Serves as a critical resource in supporting, managing, and leading strategic projects and initiatives for the Claims functional business unit. This role supports leadership in executing business and technical strategies, overseeing claims process governance, system integration, legal coordination, and compliance. Builds strong relationships with key functional areas and provides leadership and oversight to staff. Acts as a subject matter expert (SME) for claims operations, change control, and business implementations.

+ Lead Claims Process Change Control, including approval of process changes initiated internally or by partner organizations.

+ Provide claims input for business requirements related to system changes, upgrades, and partner initiatives (e.g., Auth, Payment Integrity).

+ Partner with Information Technology on automation and configuration updates, including oversight of testing and go/no-go decisions.

+ Ensure integration across claims, eligibility, provider, and utilization management systems.

+ Oversee data/reporting integration to support operational and downstream needs.

+ Coordinate claims input for legal actions and build frameworks for legal responses, including Payment Integrity and market communications.

+ Review and approve business solutions and implementation requirements for new business to ensure compliance with health plan, state, and provider contract requirements.

+ Research, define, and manage business specifications for system infrastructures for new market builds and reprocurements.

+ Maintain policies and specifications to accommodate regulatory or business changes.

+ Conduct contract reviews to identify and operationalize new or changing requirements (e.g., SLAs, reporting).

+ Oversee project plans and track key milestones for claims readiness, including readiness reviews.

+ Provide claims operations expertise for RFPs, RFIs, and audit readiness.

+ Lead process improvement initiatives in collaboration with cross-functional teams.

+ Develop and maintain policies and procedures (P&Ps) ensuring compliance with state/federal regulations, contracts, and SLAs.

+ Performs other duties as assigned.

+ Complies with all policies and standards.

**Education/Experience:** Bachelor's Degree in a related field or equivalent experience required **.** Master's Degree preferred. 5+ years experience in claims system/administration, healthcare operations, or program management required. Experience leading cross-functional teams and managing large-scale projects required. 3+ years management experience required. Regulatory knowledge of Medicare, Medicaid, and/or Marketplace required; experience with multiple products preferred. Duals product/regulatory knowledge preferred. Claims processing subject matter expertise highly preferred.

Pay Range: $105,600.00 - $195,400.00 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.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act