Clinical Policy Coding Analyst

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. Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future.

About the Role

Provides support to Clinical Policy to ensure accuracy of coding of Clinical Coverage Guidelines (CCGs) and Claims Edit Guidelines (CEGs) and maintains authorization management tools. Participates in cross-functional efforts related to claims payment policy edit changes based on clinical, financial, and claims operations perspectives. Provides support to departments across the organization as well as within Health Services regarding Clinical Policy and Procedures, governing committees, enterprise utilization management strategy, clinical effectiveness initiatives, and Authorization Rules.

Responsibilities

• Supports the Chief Medical Director of Medical Management with the evaluation of escalated disputes (and conducts necessary research) as well as review and response to complex medical coding and payment policy inquiries.
• Directs the initial review of coding in Clinical Coverage Guidelines (CCGs) to support the Medical Management Team by reviewing and updating evidence-based clinical policy (and related coding rules and regulations) to support medical necessity reviews for authorization requests.
• Leads revisions to Claims Edit Guidelines (CEGs) as well as development of new CEGs, including in-depth research of State and Federal Regulations, coding industry guidelines, and other related WellCare policies.
• Conducts research involving consistent evidence-based criteria and authorization rules in support of clinical decision-making.
• Oversees hand-off of all CCGs and CEGs to the Coding Integrity team to ensure final review of coding is completed and ensuring that necessary systems have the appropriate edits implemented.
• Supports projects delegated to the Chief Medical Director of Medical Management (e.g., liaising with claims edit vendors, Medical Expense Initiatives [MEI], strategic initiatives, Medicaid admits, authorization rules). Also includes cross-functional work and new market implementation (including vendor implementation).
• Evaluates claims coding rule change requests from clinical, financial, and claims operations perspectives, including providing regulatory and coding research for items related to Medical Expense Initiatives (MEIs), as well as changes stemming from contractual requirements, implementation activities, etc.
• Provides subject matter expertise on coding, including collaboration with markets and departments to support operations, product development, implementation, health outcomes, growth initiatives, and other business objectives.
• Follows and has a complete understanding of CMS risk adjustment guidelines and understands the impact of ICD codes on the CMS HCC risk adjustment model.
• Coordinates and reviews activities to meet contractual, regulatory, and internal department standards.
• Ensures delivery of clinical policies to the Medical Management Platform (MMP) Team (for internal posting for nurses and Medical Directors) and to Digital Communications (for posting on WellCare.com); includes auditing both access points to ensure accuracy.
• Prepares Clinical Policy Updates to notify the markets and leadership of Clinical Policy changes.
• Assists with Vendor Management to ensure coding review and implementation including updating the Auth Lookup Tool (ALT), Quick Reference Guides (QRG). Also serves as a liaison to vendors specific to external medical reviews.
• Adheres to industry and company policies related to Compliance.
• Serves as a liaison between the Medical Management team and the Systems Integration team to ensure that coding-related inquiries are addressed as CCGs are uploaded to the medical management platform for medical necessity review by the UM team.
• Maintains the authorization management tools.
• Participates in cross-functional teams on related projects (includes but is not limited to Claims, Product, Operations, and markets (implementation), and Medicare Planning for the upcoming year).
• Assists with logistics (and serves on) the Medical Policy Committee (MPC) and the Claims Payment Policy Committee (CPPC) as a coding and claims payment Subject Matter Expert (SME).
• Communicates effectively to markets, including administering communication to markets and collecting feedback.
• Performs other duties as assigned.

Requirements

• Associate's Degree in a related field or equivalent experience.
• 4+ years of experience in the medical coding field with a facility, provider, or payer organization.
• Knowledge of Medicare and Medicaid.
• Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future.

Qualifications

At least one of the following licenses or certifications is required:

• Registered Health Information Administrator (RHIA)
• Registered Health Information Technician (RHIT)
• Certified Coding Specialist (CCS)
• Certified Coding Specialist Provider-based (CCS-P)
• Certified Professional Coder (CPC or CPC-H)

Pay

$70,100.00 - $126,200.00 per year. 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

• Competitive pay
• 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

Benefits may be subject to program eligibility.