Manager, Clinical Review

🔥 0 minutes ago

🏰 Missouri – Remote

🏰 Missouri – Remote

💵 $87.7k - $157.8k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 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

• Manage the resources and results of clinical reviews resulting from providers or claims identified for potential fraud, waste and/or abuse • Manage review and audit processes for inappropriate billing practices • Develop medical strategies to correct billing issues • Review audit reports for accuracy and completeness • Present findings to Upper Management • Collaborate with providers and conduct continuous educational training on appropriate billing patterns • Support legal actions taken by the corporation, state and federal governments • Oversee implementation of improvement opportunities for effective and efficient audit processes • Collaborate with the medical management department to help define medical policy based on coding research and medical-record review • Oversee and review cost savings analysis • Meet with Medical Directors to validate medical decisions and track cost savings based on clinical denials • Lead and develop a team of clinical investigators • Review and evaluate complex Fraud, Waste & Abuse cases • Apply clinical expertise to identify trends, risks, and potential concerns • Partner with providers and internal stakeholders on complex cases • Support healthcare integrity and appropriate utilization of services • Perform other duties as assigned • Comply with all policies and standards

🎯 Requirements

• Bachelor's Degree in Nursing, a related field, or equivalent experience required for Physical Health • 5+ years of medical coding and/or nursing experience required for Physical Health • Strong medical terminology and research techniques required for Physical Health • Knowledge of CPT code billing required • Previous experience managing cross-functional teams on large-scale projects or supervisory experience, including hiring, training, assigning work, and managing staff performance, required • Clinical experience in a hospital or clinic setting, emergency room, and/or physician office preferred for Physical Health • Certified Professional Coder, RN, or LPN preferred/considered a plus • Ability to review medical records and conduct coding research • Ability to manage clinical investigators and complex healthcare integrity cases • Ability to collaborate with providers, Medical Directors, internal stakeholders, and legal entities • Compliance with all policies and standards

🏖️ 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 • Workplace flexibility • Accommodation support