Coding Quality Specialist

Centene Corporation; Town of Texas (WI); Hybrid; USD 56,000 - 101,000; Full time

Job summary

Centene Corporation is seeking a Coding Quality Coordinator II to perform complex reviews of clinical documentation in inpatient and outpatient records, ensuring accurate coding and appropriate reimbursement. You will develop written rationales and respond to providers regarding appeals, while staying current with coding guidelines.

The role requires knowledge of DRG, ICD-9/ICD-10, CPT, and HCPCS coding with several years of experience.

Qualifications

• AA in Health Information Technology preferred.
• Two years of experience with DRG, ICD-9-CM/ICD-10-CM/PCS, CPT, HCPCS coding.

Responsibilities

• Performs complex review of physician clinical documentation on inpatient and outpatient medical records.
• Performs quality analysis to determine accuracy of diagnostic and procedural coding and reimbursement.
• Develops case-specific written rationale to communicate findings to hospital, providers, and peers.
• Responds to providers for resolution of appeals.
• Identifies and interprets patterns of possible fraud or abuse and refers for further action.
• Reviews coding updates to stay current with official guidelines.
• Participates in in-service coding-related education and other duties as assigned.

Skills

Clinical documentation review

Healthcare coding knowledge

Communication with providers

Quality analysis

Regulatory awareness

Education

AA in Health Information Technology

Tools

ICD-9-CM/ICD-10-CM/PCS

CPT/HCPCS coding

Job description

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