Manager, Clinical Review

Centene Corporation•Remote-MO, MO

5d•$87,700 - $157,800•Remote

About The Position

Centene is seeking a Manager, Clinical Review to join their Medical Management/Health Services team. This is a remote clinical leadership opportunity focused on Healthcare Integrity and Fraud, Waste & Abuse (FWA). The role involves leading a team of clinical investigators, overseeing complex FWA cases, applying clinical expertise to identify potential healthcare fraud and abuse, and collaborating with providers and stakeholders across multiple markets. The position aims to manage resources and results of clinical reviews, audit inappropriate billing practices, develop medical strategies, and support legal actions. The manager will also collaborate with the medical management department on policy development and oversee cost savings analysis.

Requirements

Bachelor's Degree For Physical Health: Nursing, related field or equivalent experience required
5+ years For Physical Health: Medical coding and/or nursing experience required
For Physical Health: Strong medical terminology and research techniques required
Knowledge of CPT code billing required
Previous experience managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff required

Nice To Haves

For Physical Health: Clinical experience including hospital or clinic setting, emergency room and/or physician office preferred
For Physical Health: Certified Professional Coder. RN or LPN a plus preferred

Responsibilities

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 management 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.
Performs other duties as assigned.
Complies with all policies and standards.