Qureos Mentor

Centene

<div>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&rsquo;ll have access to competitive benefits including a fresh perspective on workplace flexibility. 
Must live in MO
Foster Care Experience Preferred
Experience with ages 13-26
Physical Health, and understanding of Behavioral health
Position Purpose: Develops, assesses, and facilitates complex care management activities for primarily physical needs members to provide high quality, cost-effective healthcare outcomes including personalized care plans and education for members and their families.<ul><li>
Evaluates the needs of the member, barriers to accessing the appropriate care, social determinants of health needs, focusing on what the member identifies as priority and recommends and/or facilitates the plan for the best outcome</li><li>
Develops ongoing care plans / service plans and collaborates with providers to identify providers, specialists, and/or community resources to address member's unmet needs</li><li>
Identifies problems/barriers to care and provide appropriate care management interventions</li><li>
Coordinates as appropriate between the member and/or family/caregivers and the care provider team to ensure members are receiving adequate and appropriate person-centered care or services</li><li>
Provides ongoing follow up and monitoring of member status, change in condition, and progress towards care plan / service plan goals; collaborate with member, caregivers, and appropriate providers to revise or update care plan / service plan as necessary to meet the member's goals / unmet needs</li><li>
Provides resource support to members and care managers for local resources for various services (e.g., employment, housing, participant direction, independent living, justice, foster care) based on service assessment and plans, as appropriate</li><li>
Facilitate care management and collaborate with appropriate providers or specialists to ensure member has timely access to needed care or services</li><li>
May perform telephonic, digital, home and/or other site outreach to assess member needs and collaborate with resources</li><li>
Collects, documents, and maintains all member information and care management activities to ensure compliance with current state, federal, and third-party payer regulators</li><li>
Provides and/or facilitates education to members and their families/caregivers on disease processes, resolving care gaps, healthcare provider instructions, care options, referrals, and healthcare benefits</li><li>
Provides feedback to leadership on opportunities to improve and enhance care and quality delivery for members in a cost-effective manner</li><li>
Other duties or responsibilities as assigned by people leader to meet business needs</li><li>
Performs other duties as assigned.</li><li>
Complies with all policies and standards.</li></ul>
Must live in MO
Foster Care Experience Preferred
Experience with ages 13-26
Physical Health, and understanding of Behavioral health
Education/Experience: Requires a Degree from an Accredited School of Nursing or a Bachelor's degree in Nursing and 2 &ndash; 4 years of related experience. 
 
License/Certification:<ul><li>
RN - Registered Nurse - State Licensure and/or Compact State Licensure required</li></ul>
Pay Range: $56,200.00 - $101,000.00 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</div>

Care Manager (RN) - Foster Care

<div>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&rsquo;ll have access to competitive benefits including a fresh perspective on workplace flexibility. 
Position Purpose: Responsible for developing and conducting a variety of training programs and/or auditing tools to provider-facing staff on quality programs, provider performance initiatives, provider tools, and field workflows.
*** The Quality Trainer I is remote. Candidates will be considered nationally. ***
Responsibilities:<ul><li>
Conduct training evaluations and needs analyses to gather feedback to determine specific training needs and improve training effectiveness for department staff.</li><li>
Apply adult learning principles to create engaging, interactive learning experiences that strengthen confidence in provider conversations and improve consistency across teams.</li><li>
Support train-the-trainer needs for market or regional facilitators, when applicable, to enable scalable rollout of enterprise training and resources.</li><li>
Identify, select, develop, and maintain appropriate training programs, including the selection or design of appropriate training aids, presentations, user guides, e-learning modules, knowledge checks, and facilitation guides.</li><li>
Collaborate with subject matter experts to evaluate effectiveness and validate content accuracy, ensuring alignment with organizational standards.</li><li>
Translate complex quality program requirements into easy-to-understand training content.</li><li>
Partner with internal business teams to ensure training reflects current program standards, expectations, and updates.</li><li>
Support rollout of new quality initiatives through training, communication, and documentation.</li><li>
Research, analyze and recommend process improvements and enhancements to training resources to strengthen program outcomes.</li><li>
Maintain version control and update cadence for training and resources to ensure staff access current, approved materials.</li><li>
Maintain records of training activities and employee progress.</li><li>
Assist in auditing work performed by staff and present findings and recommendations for areas of improvement to management.</li><li>
Assist with revisions to policy and procedures and/or work process development.</li><li>
Performs other duties as assigned.</li><li>
Complies with all policies and standards.</li></ul>
Highly Preferred Skills:<ul><li>
2+ years of adult learning and development experience including content development and facilitating to varying sizes and skill levels.</li><li>
The ability to simplify complex topics and create clear, polished documentation and training materials.</li><li>
Prior experience mentoring peers or supporting onboarding of new team members and collaborating effectively with cross-functional partners.</li><li>
Excellent communication, facilitation and writing skills.</li></ul>
Education/Experience: Bachelor's degree in related field or equivalent experience. 2+ years of training experience, preferably in a managed care or healthcare environment.
Pay Range: $56,200.00 - $101,000.00 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</div>

Quality Trainer I

<div>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&rsquo;ll have access to competitive benefits including a fresh perspective on workplace flexibility. 
***POSITION IS REMOTE NATIONWIDE***
***LOOKING FOR CANDIDATE WITH CPC OR CPMA CERTIFICATION***
Position Purpose: 
Audit medical records to identify inappropriate billing practices and recommend next steps through extensive review of claims data, medical records, corporate policy, state/federal policy, and practice standards.<ul><li>
Perform retrospective and prepayment reviews of medical records to identify potential abuse and fraud and inappropriate billing practices</li><li>
Investigate, analyze, and identify provider billing patterns to recommend payment based on medical records, claim history, billing codes, regulatory and state guidelines, and policies</li><li>
Prepare summary of findings and recommend next steps for providers</li><li>
Identify preventative measures and recommend changes to internal policies and procedures and/or provider practices to prevent future fraudulent and erroneous practices</li></ul><ul><li>
Consult investigators to identify abuse and fraud by utilizing clinical and coding expertise to analyze patterns in billing activities</li><li>
Performs other duties as assigned.</li><li>
Complies with all policies and standards.</li></ul>
Education/Experience: 
 
Associate's Degree related field or equivalent experience preferred 
 
2+ years related clinical experience in the field of obtained license required 
 
Provider education preferred 
 
Licenses/Certifications: 
Coding certification from an accredited organization (American Academy of Professional Coders or American Health Information Management Association), RN, LPC, LPN, LCSW, LMHC, PT, OT, or ST or related license. required
Pay Range: $56,200.00 - $101,000.00 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</div>

Clinical Investigator I (Special Investigation Unit)

<div>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&rsquo;ll have access to competitive benefits including a fresh perspective on workplace flexibility. 
Please note: this is a remote role with preference on candidates located in Texas.
Position Purpose: Investigate allegations of potential healthcare fraud and abuse activity. Assist in planning, organizing, and executing claims investigations or audits that identify, evaluate and measure potential healthcare fraud and abuse.<ul><li>
Conduct investigations of potential waste, abuse, and fraud</li><li>
Document activity on each case and refer issues to the appropriate party</li><li>
Perform data mining and analysis to detect aberrancies and outliers in claims</li><li>
Develop new queries and reports to detect potential waste, abuse, and fraud</li><li>
Provide case updates on progress of investigations and coordinate with Health Plans on recommendations and further actions and/or resolutions</li><li>
Assist with complex allegations of healthcare fraud</li><li>
Prepare summary and/or detailed reports on investigative findings for referral to Federal and State agencies</li><li>
Complete various special projects and audits</li><li>
Performs other duties as assigned.</li><li>
Complies with all policies and standards.</li></ul>
Education/Experience: 
Bachelor's Degree Business, Criminal Justice, Healthcare, or related field, or equivalent experience required. 1+ years Medical claim investigation, medical claim audit, medical claim analysis, or fraud investigation required.
Pay Range: $56,200.00 - $101,000.00 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</div>

SIU Investigator

<div>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&rsquo;ll have access to competitive benefits including a fresh perspective on workplace flexibility. 
Please note: this is a remote role with high preference on candidates residing within New York. 
 
Position Purpose: Investigate allegations of potential healthcare fraud and abuse activity. Assist in planning, organizing, and executing claims investigations or audits that identify, evaluate and measure potential healthcare fraud and abuse.<ul><li>
Conduct investigations of potential waste, abuse, and fraud</li><li>
Document activity on each case and refer issues to the appropriate party</li><li>
Perform data mining and analysis to detect aberrancies and outliers in claims</li><li>
Develop new queries and reports to detect potential waste, abuse, and fraud</li><li>
Provide case updates on progress of investigations and coordinate with Health Plans on recommendations and further actions and/or resolutions</li><li>
Assist with complex allegations of healthcare fraud</li><li>
Prepare summary and/or detailed reports on investigative findings for referral to Federal and State agencies</li><li>
Complete various special projects and audits</li><li>
Performs other duties as assigned.</li><li>
Complies with all policies and standards</li></ul>
Education/Experience: Bachelor's Degree Business, Criminal Justice, Healthcare, or related field, or equivalent experience required. 1+ years Medical claim investigation, medical claim audit, medical claim analysis, or fraud investigation required. Minimum of five (5) years in healthcare field working in fraud, waste and abuse investigations and audits, (or) five years of insurance claims investigation experience or professional investigation experience with law enforcement agencies, (or) seven years of professional investigation experience involving economic or insurance related matters. 
Pay Range: $56,200.00 - $101,000.00 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</div>

<div>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. 
Position Purpose: Supervises Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members. Supervises day-to-day activities of utilization management team.<ul><li>
Monitors and tracks UM resources to ensure adherence to performance, compliance, quality, and efficiency standards</li>
<li>Collaborates with utilization management team to resolve complex care member issues</li>
<li>Maintains knowledge of regulations, accreditation standards, and industry best practices related to utilization management</li>
<li>Works with utilization management team and senior management to identify opportunities for process and quality improvements within utilization management</li>
<li>Educates and provides resources for utilization management team on key initiatives and to facilitate on-going communication between utilization management team, members, and providers</li>
<li>Monitors prior authorization, concurrent review, and/or retrospective clinical review nurses and ensures compliance with applicable guidelines, policies, and procedures</li>
<li>Works with the senior management to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services</li>
<li>Evaluates utilization management team performance and provides feedback regarding performance, goals, and career milestones</li>
<li>Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards</li>
<li>Assists with onboarding, hiring, and training utilization management team members</li>
<li>Leads and champions change within scope of responsibility</li><li>
Performs other duties as assigned</li>
<li>Complies with all policies and standards</li></ul>
Education/Experience: Requires Graduate of an Accredited School Nursing or Bachelor's degree and 4+ years of related experience. 
 
Knowledge of utilization management principles preferred. 
 
License/Certification:<ul><li>
RN - Registered Nurse - State Licensure and/or Compact State Licensure required</li><li>
CA RN LICENSE REQUIRED</li></ul>
Pay Range: $75,300.00 - $135,400.00 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</div>

Supervisor, Utilization Management (RN)

<div>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. 
Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.<ul><li>
Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care</li>
<li>Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member</li>
<li>Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered</li>
<li>Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines</li>
<li>Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings</li>
<li>Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members</li>
<li>Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines</li>
<li>Reviews member&rsquo;s transfer or discharge plans to ensure a timely discharge between levels of care and facilities</li>
<li>Collaborates with care management on referral of members as appropriate</li><li>
Performs other duties as assigned.</li>
<li>Complies with all policies and standards.</li></ul>
We are seeking a Clinical Review Nurse - Concurrent Review to join our team!
The ideal candidate will bring expertise in:
IL Nursing License
 
Concurrent Review
 
Inpatient Authorizations 
Discharge Planning 
Acute and/or Critical Care
 
Computer Savvy
 
Excellent Customer Service and Communication Skills
Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor&rsquo;s degree in Nursing and 2 &ndash; 4 years of related experience. 2+ years of acute care experience required. 
 
Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. 
Knowledge of Medicare and Medicaid regulations preferred. 
Knowledge of utilization management processes preferred. 
 
License/Certification:<ul><li>
LPN - Licensed Practical Nurse - State Licensure required</li></ul>
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</div>

Clinical Review Nurse - Concurrent Review

Join Centene and explore 9   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.

Centene

About Company

Care Manager (RN) - Foster Care

Quality Trainer I

Clinical Investigator I (Special Investigation Unit)

SIU Investigator

SIU Investigator

Supervisor, Utilization Management (RN)

Clinical Review Nurse - Concurrent Review