Clinical Policy Coding Analyst

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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

• Support Clinical Policy by ensuring accurate coding of Clinical Coverage Guidelines and Claims Edit Guidelines • Maintain authorization management tools, including the Auth Lookup Tool and Quick Reference Guides • Review and update evidence-based clinical policies, coding rules, regulations, and authorization rules • Lead revisions and development of Claims Edit Guidelines • Research state and federal regulations, coding industry guidelines, and related policies • Support clinical decision-making through evidence-based criteria and authorization rules • Oversee hand-off of guidelines to the Coding Integrity team and ensure system edits are implemented • Support Chief Medical Director projects, vendor coordination, Medical Expense Initiatives, strategic initiatives, Medicaid admits, and authorization rules • Evaluate claims coding rule-change requests from clinical, financial, and claims operations perspectives • Provide regulatory and coding research for Medical Expense Initiatives and contractual or implementation changes • Serve as coding subject matter expert for markets and departments, supporting operations, product development, implementation, health outcomes, and growth initiatives • Support Medicare pre-service turnaround time and appeals projects and standardization of authorization processes • Apply CMS risk adjustment guidelines and assess ICD code impacts on the CMS HCC risk adjustment model • Coordinate activities to meet contractual, regulatory, and internal standards • Deliver clinical policies to the Medical Management Platform and Digital Communications, auditing both access points for accuracy • Prepare Clinical Policy Updates for markets and leadership • Liaise between Medical Management and Systems Integration regarding coding inquiries • Participate in cross-functional projects involving Claims, Product, Operations, markets, and Medicare Planning • Assist with logistics and serve as a coding and claims-payment subject matter expert on the Medical Policy Committee and Claims Payment Policy Committee • Communicate policy changes to markets and collect feedback • Perform other duties as assigned

🎯 Requirements

• Associate's Degree in a related field or equivalent experience • 4+ years of experience in the medical coding field with a facility, provider, or payer organization • Knowledge of Medicare and Medicaid • A required license or certification: RHIA, RHIT, CCS, CCS-P, CPC, or CPC-H • Ability to meet productivity and accuracy standards • Ability to defend coding decisions during internal and external audits • Complete understanding of CMS risk adjustment guidelines • Understanding of ICD codes and their impact on the CMS HCC risk adjustment model • Ability to meet contractual, regulatory, and internal department standards • Must be authorized to work in the U.S. without current or future employment-based visa sponsorship

🏖️ Benefits

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