Manager, Clinical Review

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.

About the role

Manage the resources and results of the clinical reviews conducted as a result of providers/claims identified for potential fraud, waste, and/or abuse. Oversee the review and audit processes of inappropriate billing practices and develop medical strategies to correct issues.

• Lead and develop a team of clinical investigators
• Review and evaluate complex Fraud, Waste & Abuse cases
• Apply clinical expertise to identify trends, risks, and potential concerns
• Partner with providers and internal stakeholders on complex cases
• Support healthcare integrity and appropriate utilization of services
• Review audit reports to ensure accuracy and completeness and present findings to Upper Management
• Collaborate with providers and conduct continuous educational training on appropriate billing patterns
• Support legal actions taken by the corporation, state, and federal governments
• Oversee the implementation of improvement opportunities to ensure effective and efficient audit processes
• Collaborate with medical management department to help define medical policy based on coding research and the review of medical records
• Oversee and review cost savings analysis and meet with Medical Director(s) to validate medical decisions and track cost savings based on clinical denials
• Perform other duties as assigned
• Comply with all policies and standards

Requirements

• Bachelor's Degree in Nursing, related field, or equivalent experience
• 5+ years of medical coding and/or nursing experience
• Strong medical terminology and research techniques
• Knowledge of CPT code billing
• Previous experience managing cross-functional teams on large-scale projects or supervisory experience including hiring, training, assigning work, and managing the performance of staff
• Clinical experience including hospital or clinic setting, emergency room, and/or physician office preferred
• Certified Professional Coder, RN, or LPN a plus

Pay

$87,700.00 - $157,800.00 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.