Analyze provider billing practices by utilizing code auditing
software, provider documentation, administrative policies,
regulatory codes, legislative directives, precedent, AMA and CMS
code edit criterion.
Review complex medical records to ensure billing is consistent
with medical record for appeals, adjustments and
miscellaneous/unlisted code review.
Review complex cases with Medical Director to validate decisions
and identify opportunities to create medical policy in the absence
Assist with research of health plan coding questions.
Identify potential billing errors, abuse, and fraud.
Identify opportunities to flag potential cases which may warrant
a prepayment review (versus an automatic system denial or
Train members of the team in medical coding reviewing
May lead team of expert witnesses defending Centene's payment
decisions in state fair hearings and health plan provider
Perform complex clinical/coding medical claim review to ensure
compliance with coding practices through a comprehensive review and
analysis of medical claims, medical records, claims history, state
regulations, contractual obligations, corporate policies and
procedures and guidelines established by the American Medical
Association and the Centers for Medicare and Medicaid Services.
Associate's degree in related field or equivalent experience.
Coding certification and 3 years of experience in medical billing &
coding, coding/data analysis, accounting/business or
physician/hospital data management or RN/LPN and 3 years of related
clinical experience. Experience in provider communication and
LPN, RN, CPC, CPC-H, CPC-P, CPC-A, CCS, CCS-P, RHIT, RHIA, or
Preferred Certification: Certified Coder
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.