Centene Corporation

Centene Corporation is seeking a qualified professional for a remote Investigative Auditor role focused on reviews of medical records to support claims and detect fraud, waste, and abuse in the healthcare system. Requires a behavioral health license and experience in utilization management, auditing, and coding. The role emphasizes verification of medical necessity, coding accuracy, and alignment with CMS and state guidelines, with collaborative work across SIU and providers. #J-18808-Ljbffr

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...