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.

Applicants for this job have the flexibility to work remote from home anywhere in the Continental United States.

Position Purpose:
Executes Line 2 oversight of Risk Adjustment activities, including monitoring, auditing, and supports Line 1 oversight. Reviews medical records to assess proper extraction of medical diagnoses and ensure accurate and complete diagnosis coding in alignment with HCCs and other risk adjustment models.

Identifies and evaluates clinical documentation gaps, assesses risk levels, and communicates findings to business stakeholders to support the integrity and quality of risk adjustment data. Collaborates with coding teams to improve documentation practices and ensure compliance with regulatory and coding guidelines.

• Ensure coding accuracy by reviewing inpatient and outpatient medical records using clinical expertise to interpret documentation in accordance with ICD-10, Coding Clinic, AHIMA, and company coding guidelines.
• Validate clinical documentation to support appropriate risk adjustment coding, including Hierarchical Condition Categories (HCCs), with emphasis on clinical relevance and site of coding clinical appropriateness.
• Apply ICD-10, AHIMA standards, Coding Clinic guidance, and company policies to ensure accurate and compliant coding practices, incorporating clinical judgment to assess documentation sufficiency.
• Implement CMS risk adjustment guideline oversight and evaluate clinical documentation to ensure alignment with regulatory standards and coding compliance.
• Review and appropriately challenge coding decisions based on clinical interpretation of documentation, current industry guidelines, audit findings, and regulatory requirements.
• Conduct Line 1 gap analyses and provide clinical best practice recommendations; design and execute Line 2 oversight to evaluate the effectiveness and compliance of risk adjustment quality programs.
• Provide expert guidance on CMS coding requirements, clinical documentation improvement (CDI), and industry best practices to coding teams and providers.
• Assess risk levels in coding data using clinical insight and recommend mitigation strategies to address potential compliance or reimbursement risks.
• Support remediation efforts for identified non-compliance issues by applying clinical knowledge to root cause analysis and corrective action planning.
• Evaluate policies and procedures to ensure completeness, clinical accuracy, and adherence to current regulatory requirements and best practices.
• Perform clinical chart reviews and advise on clinical best practices related to risk adjustment coding, HCC capture, and documentation improvement.
• Performs other duties as assigned.
• Complies with all policies and standards.

Education/Experience:

• High School Diploma or GED required
• Bachelor's Degree Nursing, Healthcare Management, Business Management or related field preferred
• 5+ years professional coding experience in a hospital or physician setting required
• Experience in Managed care preferred

Licenses/Certifications:

• LVN, LPN or RN required and
• Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) required
• NP or PAN preferred
• Certified Risk Adjustment (CRC) preferred

Pay Range: $68,700.00 - $123,700.00 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 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

Job Tags

Full time, Part time, Work at office, Work from home, Flexible hours,

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