Medical Coding Reviewer I

Centene Corporation•Remote-MO, MO

About The Position

Perform clinical and coding medical claim reviews to ensure compliance with coding practices. This includes 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. The role also supports health plan coding research, works with a Medical Director to validate decisions, and identifies potential billing issues and cases that may warrant prepayment review. Applicants must be authorized to work in the U.S. without employment-based visa sponsorship now or in the future. Sponsorship is not available for this opportunity, including for the visa types listed in the posting.

Requirements

Associate’s degree in a related field or equivalent experience.
Coding certification and at least 2 years of experience in medical billing and coding, coding or data analysis, accounting or business, or physician or hospital data management; alternatively, RN or LPN credentials and at least 2 years of related clinical experience.
One of the following licenses or certifications: LPN, RN, CPC, CPC-H, CPC-P, CPC-A, CCS, CCS-P, RHIT, RHIA, CPMA, or Paramedic.
Must be authorized to work in the U.S. without employment-based visa sponsorship now or in the future.

Nice To Haves

Experience in provider communication and education.

Responsibilities

Analyze provider billing practices using code auditing software, provider documentation, administrative policies, regulatory codes, legislative directives, precedent, and AMA and CMS code-edit criteria.
Review medical records to ensure billing is consistent with the records for appeals, adjustments, and miscellaneous or unlisted-code reviews.
Review cases with the Medical Director to validate decisions and identify opportunities to create medical policy when guidelines are absent.
Assist with research of health plan coding questions.
Identify potential billing errors, abuse, and fraud.
Identify opportunities to flag potential cases for prepayment review rather than automatic system denial or payment.
Maintain appropriate records, files, and documentation.
Perform other duties as assigned.
Comply with all policies and standards.