Clinical Reviewer II

Company: Centene Corporation
Location: Jefferson City
Posted on: January 26, 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.Perform complex retrospective and prepayment reviews of medical records to identify potential abuse and fraud and inappropriate billing practices. Responsible for second level appeals reviewsInvestigate, analyze, and identify provider billing patterns to recommend payment based on medical records, claim history, billing codes, regulatory and state guidelines, and policiesPrepare summary of findings and recommend next steps for providersIdentify preventative measures and recommend changes to internal policies and procedures and/or provider practices to prevent future fraudulent and erroneous practicesConsult investigators to identify abuse and fraud by utilizing clinical and coding expertise to analyze patterns in billing activitiesPerform onsite audits in conjunction with investigators and/or managers. Review providers' claims history, licensure, and specialty. Assess providers by interviewing staff, examining the facility and equipment, and reviewing medical recordsProvide instructions to the claims department for prepayment reviewsAssist SIU Clinical Supervisor/Manager as needed with training new hires, answering questions from Clinical Reviewer I employees, auditing work of junior-level employees, assisting with provider education, and answering questions from investigatorsThis position is a remote opportunity.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,Experience/Experience: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.Licenses/Certifications: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:** 1385618

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