Centene Corp

Clinical Policy Coding Analyst

Centene Corp • $70K — $126K *
US-AnywhereRemote in Indiana, US
Healthcare
Less than 5 years of experience
Today
Be an Early Applicant
Job Overview by Ladders

Qualifications

  • An Associate's Degree in a related field or equivalent experience required.
  • 4+ years of experience in medical coding within facility, provider, or payer organizations required.
  • Understanding of Medicare and Medicaid policies is necessary.
  • Licensure required: RHIA, RHIT, CCS, CCS-P, or CPC/CPC-H.

Responsibilities

  • Direct initial review of coding in Clinical Coverage Guidelines (CCGs) to support the Medical Management Team.
  • Conduct research involving evidence-based criteria and authorization rules.
  • Oversee hand-off of CCGs and CEGs to ensure final review of coding is completed.
  • Support projects delegated to the Chief Medical Director of Medical Management, including vendor liaison activities.
  • Evaluate claims coding rule change requests from clinical, financial, and claims operations perspectives.
  • Provide subject matter expertise on coding to support operations and business objectives.
  • Coordinate activities to meet contractual, regulatory, and internal standards.

Benefits

  • Health insurance coverage.
  • 401K and stock purchase plans.
  • Tuition reimbursement opportunities.
  • Generous paid time off plus holidays.
  • Flexible work schedule options including remote, hybrid, or office work.
Full Job Description

Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT

Position Purpose: 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 perspective. Provides support to the 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. Supports the Chief Medical Director of Medical Management with the evaluation escalated disputes (and conduct 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. Includes 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).
  • Ability to meet productivity and accuracy standards and defend coding decisions to both internal and external audits.
  • Evaluates claims coding rule change request from clinical, financial, and claims operations perspectives. Includes 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.
  • Includes projects related to Medicare pre-service turnaround time and appeals as well as ensuring efficiency of the Medical Management process inclusive of standardization in the authorization processes throughout the enterprise and any acquisitions.
  • Follows and has a complete understanding CMS risk adjustment guidelines and understands the impact of ICD codes on the CMS HCC risk adjustment model.
  • Coordinate and review 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 Update to notify the markets and leadership of Clinical Policy changes.
  • Assist 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.
  • Coordinate and review activities to meet contractual, regulatory and, internal department standards.
  • Serves as a liaison between the Medical Management team to 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 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.

Candidate Education: Required An Associate's Degree in a related field or equivalent experience.

Candidate Experience: Required 4+ years of experience in medical coding field with a facility, provider or payer organization.

Required Other Knowledge of Medicare and Medicaid

Licenses and Certifications: A license in one of the following is required: Required Other At least one of the below:

  • 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 Range: $70,100.00 - $126,200.00 per year

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules.  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 may be subject to program eligibility.

About Centene Corp

Centene Corporation is a managed healthcare enterprise at the forefront of innovation and growth for government-sponsored and commercial healthcare, providing access to fully integrated, high-quality, and cost-effective services that help people lead healthier lives. The company’s local approach addresses the needs of under-insured and uninsured individuals who often lack the resources required to sustain optimal health and wellness. Centene began as a single health plan in Milwaukee, Wisconsin in 1984. After an initial period of growth, Michael Neidorff joined as President and Chief Executive Officer (CEO) in 1996, moving Centene’s headquarters to St. Louis, Missouri, where it still resides today. In the decades since its humble beginnings, Centene has transformed into a publicly-traded Fortune 500 company serving communities across the United States. In fact, Centene provides coverage in all 50 U.S. states. More than 26 million Americans rely on Centene to access a wide range of insurance solutions, including Medicaid, Medicare, TRICARE, correctional, and behavioral health services. Centene prioritizes the development of technology that addresses systemic conditions impacting the whole health needs of underserved populations. As technology plays an increasingly critical role in diagnosing, managing, and treating disease, Centene understands that it enables better health outcomes for members, lessening the burden for providers, and allowing more automation and efficiency for business operations. As a steward of a significant set of data and insights, Centene leverages this data to not only shape but lead the digital transformation of healthcare and improve the patient-provider experience. Centene’s current CEO, Sarah London, and her team are leading the charge in this new age. Sarah London worked within Centene’s Technology Innovation and Modernization division, spearheading the company’s enterprise-wide technology strategy. Now leading Centene, her focus is on building the next generation of products and services and establishing Centene’s long-term growth and value creation. Although Centene has grown into the No. 1 insurer in the U.S. Health Insurance Marketplace, it has never lost its focus on the individual or its passion for community health. Remaining connected to the individuals and families that need care most is central to Centene’s commitment to shaping a better world of healthcare for the communities it serves. Centene also remains connected to the needs of its employees, who make Centene what it is. Through its commitment to diversity, equity, and inclusion practices, Centene promotes a safe and inviting environment above all. Because of Centene’s commitment to excellence and progression in the healthcare industry, it has been recognized as a Top Organization for Diversity by Modern Healthcare magazine, a Leading Disability Employer by the National Organization on Disability, a Best Place to Work for LGBTQ Equality by The Human Rights Campaign Foundation, and a global leader by Bloomberg’s Gender-Equality Index, among many other recognitions. Centene was also named a Top 50 Company for Diversity by DiversityInc and a Top Veteran-Friendly Company by U.S. Veterans Magazine. It has also been listed on FORTUNE® magazine's list of the World's Most Admired Companies for several consecutive years.

Centene Corp Careers

Join the dynamic team at Centene Corp, a leader in the healthcare industry, where your career growth and development are prioritized. At Centene Corp, we offer a range of job opportunities that allow you to make a significant impact on our community and beyond.

Explore a World of Opportunities

Discover the diverse career paths available at Centene Corp, from healthcare services to innovative program development. Our job opportunities span various professional fields, offering positions that cater to your unique skills and ambitions. Whether you're looking for an entry-level role or a senior leadership position, Centene Corp is committed to hiring top talent and fostering a culture of excellence.

Innovation and Leadership at Centene Corp

At Centene Corp, innovation and leadership go hand in hand. We empower our team members to lead with confidence and creativity, driving the company forward through strategic innovation and robust leadership. Our leadership programs are designed to cultivate your skills, helping you to thrive as a professional and make meaningful contributions to our company and the communities we serve.

Internships and Early Career Programs

Kickstart your career with Centene Corp through our internship and early career programs. These opportunities provide hands-on experience and a glimpse into the dynamic world of healthcare management. Internships at Centene Corp are a stepping stone to full-time employment, offering invaluable networking opportunities, mentorship, and the chance to develop your resume and interview skills in a real-world setting.

Commitment to Diversity and Inclusive Culture

Centene Corp is dedicated to maintaining a diverse and inclusive work environment. We believe that diversity fuels innovation and enhances our team's performance. Our diversity training ensures that all team members appreciate and leverage the broad range of experiences and perspectives that each individual brings to the company.

Benefits and Employee Growth

We value our employees' well-being and career aspirations. Centene Corp offers competitive benefits, including health insurance, retirement plans, and professional development programs. Our commitment to your growth is reflected in our continuous learning initiatives and performance management processes that help you achieve your career goals.

Join Our Team

Are you ready to advance your career at Centene Corp? Explore our current job openings and find the position that best matches your skills and interests. We are looking for passionate, curious, and solution-driven team players who are ready to make a difference.

Stay Connected with Centene Careers

Keep up to date with the latest career tips, insider perspectives, and industry-leading insights—all from the people who work at Centene Corp. Personalize your subscription to receive job alerts, latest news, and insider tips tailored to your preferences. Discover the exciting and rewarding opportunities that await you at Centene Corp.

SEARCH CENTENE JOBS

Centene Corp is not just a company—it's a place where you can shape your future and impact the lives of millions. Join us in our mission to transform the health of the community, one person at a time.
Learn more about Centene Corp
Size
72,500 employees
Market Cap
$46.5 billion
Industry
Healthcare
Net Income
$1.8 billion
Founded
1984
5 Year Trend
+25.4%
Revenue
$111.1 billion
NASDAQ
CNC
* Ladders Estimates

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