Medical Coding Reviewer (DRG)

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Position Purpose: Perform 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 medical records to ensure billing is consistent with medical record for appeals, adjustments and miscellaneous/unlisted code review • Review 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) • Maintain appropriate records, files, documentation, etc • Performs other duties as assigned • Complies with all policies and standards Education/Experience: Associate’s degree in related field or equivalent experience. Coding certification and 2+ years of experience in medical billing & coding, coding/data analysis, accounting/business or physician/hospital data management or RN/LPN and 2+ 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 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, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. 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