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Transforming the health of the communities we serve, one person at a time.
Manager, Clinical & Coding Review, DRG
Location
Missouri
Posted
127 days ago
Salary
$107.7K - $199.3K / year
Seniority
Lead
Job Description
Manager, Clinical & Coding Review, DRG
Centene Corporation
• Provides strategic leadership for teams performing advanced, complex claim reviews to ensure accuracy, regulatory compliance, and achievement of payment integrity goals. • This role accelerates program growth by analyzing performance trends, standardizing processes, and implementing consistent review methodologies. • Leveraging deep expertise in ICD-10, CPT/HCPCS coding, and clinical guidelines, the manager delivers actionable insights that shape operational strategies and drive informed decision-making. • Monitoring and optimizing business processes to ensure accuracy, compliance, and integrity in billing and claims payment. • Leads and mentors high-performing teams conducting advanced coding and clinical validation reviews. • Develops and maintains standardized documentation that supports business objectives and ensures consistency in review methodologies and outcomes. • Collaborates with cross-functional stakeholders to identify process improvement opportunities and champion innovative solutions. • Establishes and oversees end-to-end audit program lifecycle within Payment Integrity by setting strategic audit direction, managing and developing teams, and ensuring compliance with all regulatory, contractual, and organizational requirements.
Job Requirements
- Associate's Degree in health information management, Nursing, or a related field required
- 5+ years Managerial/Supervisory experience required
- 8+ years Complex medical claim review experience required
- 3+ years DRG review experience, Clinical Documentation Improvement experience required
- Proficiency ICD-10-CM/PCS, MS-DRG, APR-DRG required
- Proficiency Readmission, APC, EAPG, and other review types required
Benefits
- health insurance
- 401K and stock purchase plans
- tuition reimbursement
- paid time off plus holidays
- flexible approach to work with remote, hybrid, field or office work schedules
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