Supervisor, Payment Integrity- Coding & Clinical (DRG)

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

Benefits offered by this job

Health insurance

401K plans

Stock purchase plan

Tuition reimbursement

Paid time off

Job summary

Centene is seeking a Senior Manager to supervise the Coding & Clinical Review team within Payment Integrity, guiding DRG assignment, clinical validation, and audit outcomes in line with policies and regulatory requirements. You will lead staff, monitor performance, and ensure adherence to ICD-10-CM/PCS guidelines while supporting appeals and process improvements.

You will drive operational excellence, collaborate with Medical Directors and Compliance, and uphold a culture of integrity, with a

Qualifications

• Associate's Degree in Health Information Management, Nursing, or related field required
• 6+ years Performing MS-DRG and APR-DRG coding experience required
• 3+ years Conducting DRG reviews for a Payment Integrity vendor or payer experience required
• 3+ years DRG encoder/grouper experience (TruCode/TruBridge, 3M, Optum Encoder, Webstrat, PSI, or similar) experience required
• 1+ years Inpatient hospital documentation improvement, complex appeal/dispute review, or auditor education/training experience preferred

Responsibilities

• Supervise and coordinate daily work activities of Coding & Clinical Review staff to ensure timely and accurate completion of DRG audit, QA, readmissions, appeals, and/or operational workflows
• Monitor and evaluate team performance against established productivity, quality, and service level expectations; take appropriate action to address gaps
• Provide guidance and direction on coding, clinical validation, and audit determinations in accordance with ICD-10-CM/PCS guidelines, DRG methodologies, and applicable payer and regulatory policies
• Review and resolve complex or escalated cases; elevate high-risk issues to management as appropriate
• Implement and support departmental policies, procedures, and program initiatives to ensure consistent execution of Payment Integrity strategies
• Conduct quality assurance activities including audits, calibration sessions, and inter-rater reliability reviews to ensure consistency and accuracy of determinations
• Support appeals processes by reviewing clinical documentation, validating determinations, and guiding response development
• Analyze operational and audit data to identify trends, variances, and improvement opportunities; communicate findings to management
• Ensure compliance with regulatory requirements, internal policies, payer guidelines, and AHIMA ethical standards; reinforce a culture of integrity and accountability
• Collaborate with cross-functional partners (e.g., Medical Directors, Provider Relations, Compliance, Appeals) to address issues and improve outcomes
• Assist with staff selection, onboarding, training, and workforce planning
• Participate in and support process improvement efforts to enhance efficiency, quality, and financial performance
• Performs other duties as assigned.
• Complies with all policies and standards.

Skills

Leadership

Team supervision

DRG coding knowledge

Regulatory compliance

Education

Associate's Degree in Health Information Management

Tools

TruCode/TruBridge

3M Encoder

Optum Encoder

Webstrat

PSI

Job description

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.

Remote Role: Minimum experience required 6+ years Performing MS-DRG and APR-DRG coding experience and 3+ years Conducting DRG reviews for a Payment Integrity vendor or payer experience.

Position Purpose

Supervise and coordinate the day-to-day activities of the Coding & Clinical Review team within Payment Integrity, ensuring accurate diagnosis-related group assignment, clinical validation, and audit outcomes in alignment with established policies, regulatory requirements, and organizational objectives.

• Supervise and coordinate daily work activities of Coding & Clinical Review staff to ensure timely and accurate completion of DRG audit, QA, readmissions, appeals, and/or operational workflows
• Monitor and evaluate team performance against established productivity, quality, and service level expectations; take appropriate action to address gaps
• Provide guidance and direction on coding, clinical validation, and audit determinations in accordance with ICD-10-CM/PCS guidelines, DRG methodologies, and applicable payer and regulatory policies
• Review and resolve complex or escalated cases; elevate high-risk issues to management as appropriate
• Implement and support departmental policies, procedures, and program initiatives to ensure consistent execution of Payment Integrity strategies
• Conduct quality assurance activities including audits, calibration sessions, and inter-rater reliability reviews to ensure consistency and accuracy of determinations
• Support appeals processes by reviewing clinical documentation, validating determinations, and guiding response development
• Analyze operational and audit data to identify trends, variances, and improvement opportunities; communicate findings to management
• Ensure compliance with regulatory requirements, internal policies, payer guidelines, and AHIMA ethical standards; reinforce a culture of integrity and accountability
• Collaborate with cross-functional partners (e.g., Medical Directors, Provider Relations, Compliance, Appeals) to address issues and improve outcomes
• Assist with staff selection, onboarding, training, and workforce planning
• Participate in and support process improvement efforts to enhance efficiency, quality, and financial performance
• Performs other duties as assigned.
• Complies with all policies and standards.

Education & Experience

• Associate's Degree in Health Information Management, Nursing, or related field required
• 6+ years Performing MS-DRG and APR-DRG coding experience required
• 3+ years Conducting DRG reviews for a Payment Integrity vendor or payer experience required
• 3+ years DRG encoder/grouper experience (TruCode/TruBridge, 3M, Optum Encoder, Webstrat, PSI, or similar) experience required
• 1+ years Inpatient hospital documentation improvement, complex appeal/dispute review, or auditor education/training experience preferred

Licenses & Certifications

• RHIT - Registered Health Information Technician required
• CCS-Certified Coding Specialist required
• (CIC) required
• Certified Clinical Documentation Specialist (CCDS) required
• RN - Registered Nurse - State Licensure and/or Compact State Licensure Registered Nurse (in combination with a coding credential) preferred

Pay Range

$87,700.00 - $157,800.00 per year

Benefits

• competitive pay
• health insurance
• 401K and stock purchase plans
• tuition reimbursement
• paid time off plus holidays
• 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.

Equal Opportunity & Diversity

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

Should you need an accommodation, please email [e-mail].

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.