Medical Coding Reviewer Ii

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.
Position Purpose: Perform complex clinical/coding medical claim review to ensure compliance with coding practices through a comprehensive review and analysis of medical claims, medical records, claims history, state regulations, contractual obligations, corporate policies and procedures and guidelines established by the American Medical Association and the Centers for Medicare and Medicaid Services.
Analyze provider billing practices by utilizing code auditing software, provider documentation, administrative policies, regulatory codes, legislative directives, precedent, AMA and CMS code edit criterion.
Review complex medical records to ensure billing is consistent with medical record for appeals, adjustments and miscellaneous/unlisted code review.
Review complex cases with Medical Director to validate decisions and identify opportunities to create medical policy in the absence of guidelines.
Assist with research of health plan coding questions.
Identify potential billing errors, abuse, and fraud.
Identify opportunities to flag potential cases which may warrant a prepayment review (versus an automatic system denial or payment).
Train members of the team in medical coding reviewing practices.
May lead team of expert witnesses defending Centene’s payment decisions in state fair hearings and health plan provider calls.
Education/Experience: Associate’s degree in related field or equivalent experience. Coding certification and 3+ years of experience in medical billing & coding, coding/data analysis, accounting/business or physician/hospital data management or RN/LPN and 3+ years of related clinical experience. Experience in provider communication and education preferred. License/Certification: LPN, RN, CPC, CPC-H, CPC-P, CPC-A, CCS, CCS-P, RHIT, RHIA, CPMA, or Paramedic
Our Comprehensive Benefits Package: Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.
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.