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Clinical Reviewer II

Company: Centene Corporation
Location: Jefferson City
Posted on: January 25, 2023

Job Description:

You could be the one who changes everything for our 26 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.

Review medical records to determine if bills submitted by providers match the supporting documentation

Assist the health plans with preventative measures including educational materials, payment holds, new/changed payment policies, etc.

Meet with Medical Director(s) to validate medical decisions and track cost savings based on clinical denials

Identify billing isssues that can be resolved through claim system editing

Use antifraud detection software to create reports that identify potential high dollar cases and provide medical guidance for potential abuse and fraud cases

Providing medical guidance for potential waste, abuse, and fraud cases

Position Purpose:
Audit medical records to identify inappropriate billing practices and determine medical necessity through extensive review of claims data, medical records, corporate policies, state/federal policies, and the interpretation of practice standards,

Associate's degree in Nursing, Counseling, or related field. Coding Certification and 4+ years of medical coding experience; or RN, LPC, LCSW, LMHC, PT, OT or ST license and 4+ years of related clinical experience in the field of obtained license. Experience in provider education preferred. Experience in a managed care organization preferred. Experience in medical record auditing preferred.

Coding certification from an accredited organization (American Academy of Professional Coders or American Health Information Management Association), RN, LPC, LCSW, LMHC, PT, OT, or ST.

Our Comprehensive Benefits Package: Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

**TITLE:** Clinical Reviewer II

**LOCATION:** Various, Missouri

**REQNUMBER:** 1397527

Keywords: Centene Corporation, Jefferson City , Clinical Reviewer II, Other , Jefferson City, Missouri

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