Manager, Clinical Review

Centene Management Company LLC; Missouri; Hybrid; USD 88,000 - 158,000; Full time

Benefits offered by this job

Remote work options

401K and stock purchase plans

Tuition reimbursement

Paid time off + holidays

Job summary

Centene is seeking a Manager, Clinical Review for a remote leadership role within Healthcare Integrity. You will lead a team of clinical investigators, oversee complex Fraud, Waste & Abuse cases, and apply your clinical expertise across multiple markets to identify trends and risks.

You will partner with providers and internal stakeholders to ensure appropriate utilization of services, drive cost-saving initiatives, and support legal actions as required.

Qualifications

• Bachelor's degree in nursing or related field with 5+ years of clinical review/leadership.
• Medical coding and/or nursing experience required.
• Strong medical terminology and CPT coding knowledge.
• Certified Professional Coder (CPC) preferred; RN/LPN a plus.
• Experience leading cross-functional teams on large projects.
• Experience in healthcare fraud, waste & abuse investigations a plus.

Responsibilities

• Manage resources and results of clinical reviews for potential FWA.
• Oversee audit processes of inappropriate billing practices.
• Develop medical strategies to correct issues and review audit reports.
• Collaborate with providers and legal/government actions as needed.
• Define medical policy based on coding research and records review.
• Lead cost savings analyses and validate medical decisions with Medical Directors.

Skills

Clinical leadership

Team management

Fraud, Waste & Abuse awareness

CPT coding knowledge

Medical terminology

Research techniques

Cross-functional collaboration

Education

Bachelor's degree in nursing or related field

Medical coding and/or nursing experience

Certified Professional Coder (CPC) preferred

RN or LPN a plus

Job description

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.

Centene is Hiring: Manager, Clinical Review Remote Clinical Leadership Opportunity | Healthcare Integrity | Fraud, Waste & Abuse

Are you a nurse leader with experience in Clinical Review, SIU, Fraud, Waste, Abuse & Coding? This could be your next leadership opportunity.

Join Centene in a remote clinical leadership role where you’ll lead a team of clinical investigators, oversee complex FWA cases, apply your clinical expertise to identify potential healthcare fraud and abuse, and collaborate with providers and key stakeholders across multiple markets.

What makes this opportunity stand out?

• Lead and develop a team of clinical investigators
• Review and evaluate complex Fraud, Waste & Abuse cases
• Apply clinical expertise to identify trends, risks, and potential concerns
• Partner with providers and internal stakeholders on complex cases
• Support healthcare integrity and appropriate utilization of services
• Make an impact across multiple markets while working 100% remotely

If you have a strong clinical background and are ready to take your expertise into healthcare investigations and clinical leadership, this is an opportunity worth exploring.

Position Purpose:

Manage the resources and results of the clinical reviews that are conducted as a result of providers/claims identified for potential fraud, waste and/or abuse. Manage the review and audit processes of inappropriate billing practices and develop medical strategies to correct issues Review audit reports to ensure accuracy and completeness and present findings to Upper Management Collaborate with providers and conduct continuous educational training on appropriate billing patterns Support legal actions taken by the corporation, state and federal governments Oversee the implementation of improvement opportunities to ensure effective and efficient audit processes Collaborate with medical management department to help define medical policy based on coding research and the review of medical records Oversee and review cost savings analysis and meet with Medical Director(s) to validate medical decisions and track cost savings based on clinical denials Performs other duties as assigned Complies with all policies and standards

Education/Experience:

• Bachelor's Degree For Physical Health: Nursing, related field or equivalent experience required 5+ years
• For Physical Health: Medical coding and/or nursing experience required
• For Physical Health: Strong medical terminology and research techniques required Knowledge of CPT code billing required
• Previous experience managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff required
• For Physical Health: Clinical experience including hospital or clinic setting, emergency room and/or physician office preferred
• For Physical Health: Certified Professional Coder. RN or LPN a plus preferred

Pay Range:

$87,700.00 - $157,800.00 per year

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 applicable 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.

Thanks for your interest in Centene and its subsidiary companies.

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Centene is committed to helping people live healthier lives. We provide access to high-quality healthcare, innovative programs and a wide range of health solutions that help families and individuals get well, stay well and be well.