Centene Corporation Manager, Clinical Review in Chesterfield, Missouri

ProfessionalPosition Purpose: Manage the resources and results of the clinical reviews that are conducted as a result of providers/claims identified for potential fraud, waste and/or abuse.

  • Manage the review and audit processes of inappropriate billing practices and develop medical strategies to correct issues

  • 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 managment 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

Education/Experience: Bachelor’s degree in Nursing, related field, or equivalent experience. 5+ years of combined medical coding and nursing experience. Knowledge of CPT code billing. Strong medical terminology and research techniques required. Clinical experience including hospital or clinic setting, emergency room and/or physician office a plus. Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff.

Licenses/Certifications: Certified Professional Coder. RN or LPN a plus.

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.

TITLE: Manager, Clinical Review

LOCATION: Chesterfield, Missouri

REQNUMBER: 1110127

COMPANY: Clinical & Nursing

POSITION TYPE: Professional