Manager, Clinical & Coding Review, DRG
Centene Corporation
full-time
Posted on:
Location Type: Remote
Location: Montana • United States
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Salary
💰 $107,700 - $199,300 per year
About the role
- 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.
- Monitoring and optimizing business processes 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.
- Collaborates with cross-functional stakeholders to identify process improvement opportunities and champion innovative solutions.
- Establishes and oversees end-to-end audit program lifecycle within Payment Integrity by setting strategic audit direction, managing and developing teams, and ensuring compliance with all regulatory, contractual, and organizational requirements.
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
Benefits
- health insurance
- 401K and stock purchase plans
- tuition reimbursement
- paid time off plus holidays
- flexible approach to work with remote, hybrid, field or office work schedules
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
ICD-10CPT codingHCPCS codingDRG reviewClinical Documentation ImprovementMS-DRGAPR-DRGReadmission reviewAPC reviewEAPG review
Soft Skills
strategic leadershipmentoringcollaborationprocess improvementanalytical skillsdecision-makingteam managementcommunicationorganizational skillsproblem-solving
Certifications
Associate's Degree in health information managementNursing degree