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Medical Coding Reviewer I
Centene Corporation. Perform clinical/coding medical claim review to ensure compliance with coding practices .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical coding and medical claim review, ensuring compliance with AMA and CMS guidelines while identifying billing errors and fraud. Proficient in provider communication and education, with a strong foundation in medical billing and coding practices.
Highest-signal resume keywords
Medical Claim ReviewCoding Certification2+ Years Experience in Medical Billing & CodingProvider CommunicationRegulatory Compliance
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
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Hard Skills
Clinical CodingMedical Claim ReviewData AnalysisBilling Practices AnalysisCoding Auditing SoftwareMedical Record ReviewBilling Error IdentificationPrepayment ReviewHealth Plan Coding ResearchDocumentation Maintenance
Soft Skills
CommunicationCollaborationProblem-SolvingAttention to DetailAnalytical Thinking
Certifications & Qualifications
CPCCPC-HCPC-PCPC-ACCSCCS-PRHITRHIACPMALPN
Industry Keywords
AMA GuidelinesCMS GuidelinesState RegulationsCorporate PoliciesLegislative DirectivesProvider DocumentationBilling ComplianceMedical Policy DevelopmentClaims HistoryContractual Obligations
About the role
Key responsibilities & impact- Perform clinical/coding medical claim review to ensure compliance with coding practices
- Review and analyze medical claims, medical records, claims history, state regulations, contractual obligations, corporate policies and procedures, AMA guidelines, and CMS guidelines
- Analyze provider billing practices using code auditing software, provider documentation, administrative policies, regulatory codes, legislative directives, precedent, and AMA/CMS code edit criteria
- Review medical records to ensure billing is consistent with medical records for appeals, adjustments, and miscellaneous/unlisted code review
- Review cases with Medical Director to validate decisions and identify opportunities to create medical policy where guidelines are absent
- Assist with research of health plan coding questions
- Identify potential billing errors, abuse, and fraud
- Identify potential cases warranting prepayment review
- Maintain appropriate records, files, and documentation
- Perform other duties as assigned
- Comply with all policies and standards
Requirements
What you’ll need- Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future
- 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
- License/certification: LPN, RN, CPC, CPC-H, CPC-P, CPC-A, CCS, CCS-P, RHIT, RHIA, CPMA, or Paramedic
- Experience in provider communication and education preferred
Benefits
Comp & perks- competitive pay
- health insurance
- 401K and stock purchase plans
- tuition reimbursement
- paid time off plus holidays
- flexible approach to work with remote, hybrid, field or office work schedules
- Additional forms of incentives may be included in total compensation
- Benefits may be subject to program eligibility