Coding Quality Specialist

Centene Corporation; Austin (TX); Hybrid; USD 56,000 - 101,000; Full time

Benefits offered by this job

Competitive pay

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off + holidays

Flexible work arrangements

Job summary

Centene, a leading healthcare enterprise, seeks a Coding Quality Coordinator II to perform complex reviews of clinical documentation on inpatient and outpatient medical records. You will validate diagnostic and procedural coding accuracy, determine payment methodology, and develop written rationales for reviewer teams and providers.

Ideal candidates have an AA in Health Information Technology and 2+ years of DRG/ICD-9-CM/ICD-10-CM/PCS coding experience, with relevant certifications such as

Qualifications

• Complex reviews of physician clinical documentation for inpatient and outpatient records.
• Quality analysis to ensure correct diagnostic/procedural coding and coding guidelines.
• Submit case-specific rationale to substantiate findings to hospitals, providers and review teams.

Responsibilities

• Performs complex review of physician clinical documentation on inpatient and outpatient medical records.
• Determines correct payment methodology and reimbursement.
• Develops case-specific written rationale to communicate findings to hospital, provider, medical director and peer review team.
• Responds to providers for resolution of appeals.
• Keeps up to date with Coding Clinics, coding newsletters and other professional resources.

Skills

Clinical documentation review

Medical coding accuracy

Payment methodology

Provider communication

Fraud detection

Education

AA in Health Information Technology

RHIA/RHIT/CCS/CCA/CPC certifications

Job description

Business Area: Administrative & Claims Operations

Job Type: Full time

Position Purpose: The Coding Quality Coordinator II is the journey level position within a job series that performs complex reviews of clinical documentation on inpatient and outpatient medical records. Validates accuracy of diagnostic and procedural coding, payment methodology, and reimbursement amount; develops written rationale of findings; responds to providers for resolution of appeals.

Key Details: Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT.

• Performs complex review of physician clinical documentation on inpatient and outpatient medical records.
• Performs quality analysis to determine accuracy of diagnostic and procedural coding, the correct interpretation and application of official coding guidelines and rules, and assignment of appropriate codes.
• Determines correct payment methodology and reimbursement.
• Develops case-specific written rationale to substantiate and communicate findings to hospital, provider, medical director, and peer review team.
• Conducts coding re-review for decisions that are based on coding convention and sequencing guidelines, not requiring medical review.
• Identifies clinical questions and refers cases to Medical Director.
• Responds to providers for resolution of appeals.
• Reviews updates to Coding Clinics, coding newsletters, and other professional resources to maintain up-to-date knowledge.
• Participates in ongoing in-service programs for coding-related or clinical education.
• Identifies and interprets patterns of possible fraud or abuse and refers to appropriate party for further evaluation and corrective action.
• Conducts periodic peer reviews.
• Other duties as assigned.
• Performs other duties as assigned.
• Complies with all policies and standards.

Education/Experience: AA, Health Information Technology, preferred. Two years experience with Diagnosis Related Groups (DRG), ICD-9-CM/ ICD-10-CM/PCS, CPT, HCPCS coding.

License/Certification: One or more of the following certifications may be required: Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Coding Associate (CCA), or Certified Professional Coder (CPC)Pay Range: $56,200.00 - $101,000.00 per year

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

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.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act