Manager, Clinical & Coding Review (DRG)

Centene Corporation

2d•Remote

About The Position

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. POSITION IS REMOTE CANDIDATE MUST HAVE PEOPLE LEADER AND DRG EXPERIENCE Position Purpose: Provides strategic leadership for teams performing advanced, complex claim reviews to ensure accuracy, regulatory compliance, and achievement of payment integrity goals. This role accelerates program growth by analyzing performance trends, standardizing processes, and implementing consistent review methodologies. Leveraging deep expertise in ICD-10, CPT/HCPCS coding, and clinical guidelines, the manager delivers actionable insights that shape operational strategies and drive informed decision-making. Additionally, this position cultivates a high-performance culture focused on continuous improvement, accountability, and professional development across both the team and the broader program. Monitors and optimizes business processes and systems to ensure accuracy, compliance, and integrity in billing and claims payment. Leads and mentors high-performing teams conducting advanced coding and clinical validation reviews. Develops and maintains standardized documentation that supports business objectives and ensures consistency in review methodologies and outcomes. Provides strategic leadership to review teams, fostering a culture of quality, accountability, and continuous improvement. Collaborates with cross-functional stakeholders to identify process improvement opportunities and champion innovative solutions. Directs team operations by assigning priorities, setting goals, and coordinating daily activities. Maintain transparent communication through regular one-on-one and team meetings. Establishes and oversees the end-to-end audit program lifecycle within Payment Integrity by setting strategic audit direction, managing and developing teams, and ensuring full compliance with all regulatory, contractual, and organizational requirements. Applys advanced expertise in ICD-10 coding, clinical guidelines, and Centene/Health Plan policies, incorporating updates from CMS, state regulations, and contractual obligations to guide review outcomes and operational decisions. Drives documentation initiatives that align with business objectives, ensuring consistency and identifying high-value review opportunities within the complex review roadmap. Analyzes audit trends and DRG adjustments to inform scalable program development and identify emerging review opportunities within DRG and other review types. Oversees program expansion by implementing new complex review types, facilitating cross-departmental collaboration, and integrating robust review protocols for audit operations. Performs other duties as assigned. Complies with all policies and standards.

Requirements

Associate's Degree in health information management, Nursing, or a related field required
5+ years Managerial/Supervisory experience required
8+ years Complex medical claim review experience required
3+ years DRG review experience, Clinical Documentation Improvement experience required
Proficiency ICD-10-CM/PCS, MS-DRG, APR-DRG required
Proficiency Readmission, APC, EAPG, and other review types required
RHIA - Registered Health Information Administrator required or RHIT - Registered Health Information Technician required or: CCS-Certified Coding Specialist required or: Clinical Inpatient Coder (CIC) required or: Certified Clinical Documentation Specialist (CCDS) required or: CDIP - Clinical Documentation Improvement Professional preferred or: RN - Registered Nurse - State Licensure and/or Compact State Licensure in combination with a coding credential preferred

Responsibilities

Monitors and optimizes business processes and systems to ensure accuracy, compliance, and integrity in billing and claims payment.
Leads and mentors high-performing teams conducting advanced coding and clinical validation reviews.
Develops and maintains standardized documentation that supports business objectives and ensures consistency in review methodologies and outcomes.
Provides strategic leadership to review teams, fostering a culture of quality, accountability, and continuous improvement.
Collaborates with cross-functional stakeholders to identify process improvement opportunities and champion innovative solutions.
Directs team operations by assigning priorities, setting goals, and coordinating daily activities.
Maintain transparent communication through regular one-on-one and team meetings.
Establishes and oversees the end-to-end audit program lifecycle within Payment Integrity by setting strategic audit direction, managing and developing teams, and ensuring full compliance with all regulatory, contractual, and organizational requirements.
Applys advanced expertise in ICD-10 coding, clinical guidelines, and Centene/Health Plan policies, incorporating updates from CMS, state regulations, and contractual obligations to guide review outcomes and operational decisions.
Drives documentation initiatives that align with business objectives, ensuring consistency and identifying high-value review opportunities within the complex review roadmap.
Analyzes audit trends and DRG adjustments to inform scalable program development and identify emerging review opportunities within DRG and other review types.
Oversees program expansion by implementing new complex review types, facilitating cross-departmental collaboration, and integrating robust review protocols for audit operations.
Performs other duties as assigned.
Complies with all policies and standards.