Manager, Clinical, Coding Review

🕒 Yesterday

🐊 Florida, Michigan, +1 more states – Remote

🐊 Florida – Remote 🚗 Michigan – Remote 🏰 Missouri – Remote

💵 $107.7k - $199.3k / year

⏰ Full Time

🟠 Senior

🔴 Lead

👔 Manager

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Centene Corporation

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1984

🛡️ Insurance

💼 Consulting

🏥 Healthcare

Insurance • Consulting • Healthcare

Centene Corporation is a leading provider of government-sponsored healthcare services, specializing in delivering affordable and high-quality healthcare solutions. For over 40 years, Centene has focused on transforming the health of communities by expanding access to Medicaid, Medicare, and Health Insurance Marketplace services, as well as serving military communities through the TRICARE program. As the largest Medicaid managed care organization and a key participant in the Marketplace, Centene emphasizes localized healthcare delivery combined with strong partnerships with nonprofit organizations to meet the unique needs of its members. Centene is also committed to corporate sustainability and social responsibility, prioritizing environmental stewardship and ethical governance to enhance the well-being of the communities it serves.

📋 Description

• Provide strategic leadership for teams performing advanced, complex claim reviews • Ensure review accuracy, regulatory compliance, and achievement of payment integrity goals • Analyze performance trends and standardize processes and review methodologies • Deliver actionable insights using ICD-10, CPT/HCPCS coding, and clinical guidelines • Monitor and optimize business processes and systems for billing and claims payment integrity • Lead and mentor teams conducting advanced coding and clinical validation reviews • Develop and maintain standardized documentation supporting business objectives and consistent review outcomes • Collaborate with cross-functional stakeholders to identify process improvements and implement innovative solutions • Assign priorities, set goals, and coordinate daily team activities • Maintain transparent communication through regular one-on-one and team meetings • Establish and oversee the end-to-end Payment Integrity audit program lifecycle • Set strategic audit direction, manage and develop teams, and ensure regulatory, contractual, and organizational compliance • Apply ICD-10 coding, clinical guidelines, Centene/Health Plan policies, CMS updates, state regulations, and contractual obligations to review outcomes • Analyze audit trends and DRG adjustments to support scalable program development and identify emerging review opportunities • Oversee expansion into new complex review types and integrate review protocols for audit operations • Perform other duties as assigned and comply with all policies and standards

🎯 Requirements

• Associate's Degree in health information management, Nursing, or a related field required • 5+ years of managerial/supervisory experience required • 8+ years of complex medical claim review experience required • 3+ years of DRG review experience required • 3+ years of Clinical Documentation Improvement experience required • Proficiency in ICD-10-CM/PCS, MS-DRG, and APR-DRG required • Proficiency in Readmission, APC, EAPG, and other review types required • One of the following required: RHIA, RHIT, CCS, Clinical Inpatient Coder (CIC), or Certified Clinical Documentation Specialist (CCDS) • CDIP preferred • RN state licensure and/or compact state licensure combined with a coding credential preferred • Must be authorized to work in the U.S. without employment-based visa sponsorship now or in the future • Willingness to travel up to 25%

🏖️ Benefits

• Competitive pay • Health insurance • 401K plans • Stock purchase plans • Tuition reimbursement • Paid time off plus holidays • Flexible approach to work with remote, hybrid, field or office work schedules • Additional forms of incentives may be included in total compensation