Medical Coding Reviewer I

Centene Corporation; Missouri; Hybrid; USD 65,000 - 95,000; Full time

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off and holidays

Flexible work arrangements

Job summary

Centene Corporation seeks a qualified clinical/coding medical claims reviewer to ensure billing compliance and accurate coding through comprehensive review of claims, records, and guidelines.

The role involves collaborating with Medical Directors, researching coding questions, and flagging cases for prepayment reviews when appropriate, with a strong emphasis on accuracy and policy adherence.

Qualifications

• Associate degree or equivalent experience; coding certification preferred.
• 2+ years in medical billing and coding, coding/data analysis, or related clinical experience.
• Licensure/certification options include LPN, RN, CPC, CPC-H, CPC-P, CPC-A, CCS, CCS-P, RHIT, RHIA, CPMA, or Paramedic.

Responsibilities

• Analyze provider billing practices using code auditing software and regulatory codes.
• Review medical records for coding consistency and for appeals/adjustments.
• Consult with Medical Director to validate decisions and identify policy gaps.
• Research health plan coding questions as needed.
• Identify potential billing errors, abuse, and fraud.
• Flag cases for prepayment review when appropriate.
• Maintain records and documentation.
• Perform other duties as assigned.
• Comply with all policies and standards.

Skills

Billing analysis

Medical records review

Regulatory compliance

Fraud detection

Prepayment review

Education

Associate’s degree

Coding certification

RN/LPN

Tools

Code auditing software

Job description

Position Purpose:
Perform clinical/coding medical claim review to ensure compliance with coding practices through a comprehensive review and analysis of medical claims, medical records, claims history, state regulations, contractual obligations, corporate policies and procedures and guidelines established by the American Medical Association and the Centers for Medicare and Medicaid Services.

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.

• Analyze provider billing practices by utilizing code auditing software, provider documentation, administrative policies, regulatory codes, legislative directives, precedent, AMA and CMS code edit criterion
• Review medical records to ensure billing is consistent with medical record for appeals, adjustments and miscellaneous/unlisted code review
• Review cases with Medical Director to validate decisions and identify opportunities to create medical policy in the absence of guidelines
• Assist with research of health plan coding questions
• Identify potential billing errors, abuse, and fraud
• Identify opportunities to flag potential cases which may warrant a prepayment review (versus an automatic system denial or payment)
• Maintain appropriate records, files, documentation, etc
• Performs other duties as assigned
• Complies with all policies and standards

Education/Experience:
Associate’s degree in related field or equivalent experience. Coding certification and 2+ years of experience in medical billing & coding, coding/data analysis, accounting/business or physician/hospital data management or RN/LPN and 2+ years of related clinical experience. Experience in provider communication and education preferred.
License/Certification: LPN, RN, CPC, CPC-H, CPC-P, CPC-A, CCS, CCS-P, RHIT, RHIA, CPMA, or Paramedic

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