Clinical Policy Coding Analyst

Centene Corporation•Remote-IN, IN

13d•$70,100 - $126,200•Hybrid

About The Position

Centene is seeking a Clinical Policy Coding Analyst to join their team. This role is crucial in ensuring the accuracy of coding for Clinical Coverage Guidelines (CCGs) and Claims Edit Guidelines (CEGs), and maintaining authorization management tools. The analyst will participate in cross-functional efforts related to claims payment policy edits, provide support to various departments on clinical policy and procedures, and assist the Chief Medical Director of Medical Management with escalated disputes and complex coding inquiries. The position involves in-depth research of state and federal regulations, industry guidelines, and company policies, as well as overseeing the hand-off of coding guidelines to the Coding Integrity team. The analyst will also support projects delegated to the Chief Medical Director, including liaising with claims edit vendors and supporting new market implementations. A key aspect of the role is the ability to meet productivity and accuracy standards and defend coding decisions. The analyst will evaluate coding rule change requests, provide subject matter expertise, and ensure the efficiency of the Medical Management process. Understanding CMS risk adjustment guidelines and their impact on the HCC model is essential. The role also involves coordinating activities to meet contractual and regulatory standards, ensuring the delivery of clinical policies to relevant teams, and preparing policy updates. Vendor management for coding review and implementation, adherence to compliance policies, and serving as a liaison between various teams are also key responsibilities. The analyst will participate in cross-functional teams on related projects and assist with the Medical Policy Committee (MPC) and Claims Payment Policy Committee (CPPC) as a Subject Matter Expert (SME). Effective communication with markets and performing other duties as assigned are also part of the role.

Requirements

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
An Associate's Degree in a related field or equivalent experience.
4+ years of experience in medical coding field with a facility, provider or payer organization.
Knowledge of Medicare and Medicaid
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)

Nice To Haves

Follows and has a complete understanding CMS risk adjustment guidelines and understands the impact of ICD codes on the CMS HCC risk adjustment model.

Responsibilities

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.
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).
Evaluates claims coding rule change request from clinical, financial, and claims operations perspectives.
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.
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).
Adheres to industry and company policies related to Compliance.
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.