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.
 

****NOTE: This fully remote role involves completing clinical and payment policy ideation, review, vetting and development for all lines of business as part of the payment policy operating model. Preference will be given to applicants (1) based in central, eastern or mountain time zone of the United States, (2) are experienced with research, analysis, and drawing conclusions, (3) and knowledgeable of claims adjudication processes and procedures as well as state-specific Medicaid rules.****

Position Purpose: Minimize FWA (fraud, waste, and abuse) by performing medical claim reviews to ensure compliance with coding guidelines through a comprehensive review and analysis of claims, medical records, claims history, state regulations, contractual obligations, corporate policies, procedures and guidelines. Perform analyses and interpretation to link to business needs & objectives of Corporate and health plans.

• Provide coding/clinical decisions on first time claims, adjustments and appeals in accordance with correct coding guidelines and Centene payment policies.
• Lead team of expert witnesses defending Centene’s payment decisions in state fair hearings and health plan provider calls.
• Develop and maintain review guidelines for Corporate medical coding reviews.
• Performs other duties as assignedComplies with all policies and standards

Education/Experience: Associate's Degree Nursing or related field required

4+ years Medical Coding Experience required: Experience in provider education, medical record auditing, and in a managed care organization
preferred

RN - Registered Nurse - State Licensure and/or Compact State Licensure required or
LPN - Licensed Practical Nurse - State Licensure required or

CPC, CPC-H, CPC-P or CPC-A required or: CCS or CCS-P required or
RHIT or RHIA required or
PARAMEDIC - Paramedic – Licensed required or
CPMA required or
Medical Record Technician (MRT) required:

****Additional Details:
• Department: Medical Affairs Ops ****

Pay Range: $32.41 - $58.31 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.  Total compensation may also include additional forms of incentives.

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