Manager, Clinical & Coding Review

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 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. Additionally, this position cultivates a high-performance culture focused on continuous improvement, accountability, and professional development across both the team and the broader program.

This is a remote role with up to 25% travel.

Responsibilities

• Monitors and optimizes business processes and systems 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.
• Provides strategic leadership to review teams, fostering a culture of quality, accountability, and continuous improvement.
• Collaborates with cross-functional stakeholders to identify process improvement opportunities and champion innovative solutions.
• Directs team operations by assigning priorities, setting goals, and coordinating daily activities. Maintains transparent communication through regular one-on-one and team meetings.
• Establishes and oversees the end-to-end audit program lifecycle within Payment Integrity by setting strategic audit direction, managing and developing teams, and ensuring full compliance with all regulatory, contractual, and organizational requirements.
• Applies advanced expertise in ICD-10 coding, clinical guidelines, and Centene/Health Plan policies, incorporating updates from CMS, state regulations, and contractual obligations to guide review outcomes and operational decisions.
• Drives documentation initiatives that align with business objectives, ensuring consistency and identifying high-value review opportunities within the complex review roadmap.
• Analyzes audit trends and DRG adjustments to inform scalable program development and identify emerging review opportunities within DRG and other review types.
• Oversees program expansion by implementing new complex review types, facilitating cross-departmental collaboration, and integrating robust review protocols for audit operations.
• Performs other duties as assigned.
• Complies with all policies and standards.

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 in ICD-10-CM/PCS, MS-DRG, APR-DRG required.
• Proficiency in Readmission, APC, EAPG, and other review types required.

Qualifications

• RHIA - Registered Health Information Administrator required, OR
• RHIT - Registered Health Information Technician required, OR
• CCS - Certified Coding Specialist required, OR
• Clinical Inpatient Coder (CIC) required, OR
• Certified Clinical Documentation Specialist (CCDS) required, OR
• CDIP - Clinical Documentation Improvement Professional preferred, OR
• RN - Registered Nurse - State Licensure and/or Compact State Licensure in combination with a coding credential preferred.

Pay

$107,700.00 - $199,300.00 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.