Manager, Clinical Review

Centene
Missouri
Workplace: RemoteFull timeUSD 87,700 - 157,800 annuallyFunction: Healthcare (Clinical, Medical, Wellness)Experience: 5+ yearsEducation: bachelorsSkills: ["Leadership","Collaboration","Analysis","Communication","Stakeholder management"]

Lead clinical investigations focused on Fraud, Waste & Abuse (FWA) within Centene’s Medical Management/Health Services team. Manage clinical reviewers, oversee complex case review and audit processes for inappropriate billing, and present accurate findings to upper management. Partner with providers and internal stakeholders across markets, support healthcare integrity and appropriate utilization, and collaborate with medical directors on coding research, denials, and cost savings. Work fully remotely.

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Centene
Centene
2 days ago

Manager, Clinical Review

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Last checked: 11 hours agoStatus: Live

Job Summary

Lead clinical investigations focused on Fraud, Waste & Abuse (FWA) within Centene’s Medical Management/Health Services team. Manage clinical reviewers, oversee complex case review and audit processes for inappropriate billing, and present accurate findings to upper management. Partner with providers and internal stakeholders across markets, support healthcare integrity and appropriate utilization, and collaborate with medical directors on coding research, denials, and cost savings. Work fully remotely.
Location: Missouri
Workplace: Remote
Employment Type: Full time
Job Function: Healthcare (Clinical, Medical, Wellness)
Seniority: Manager level

Key Responsibilities

  • •Manage resources and results of clinical reviews for potential fraud, waste, and/or abuse identified from providers/claims.
  • •Oversee review and audit processes for inappropriate billing practices and develop medical strategies to correct issues.
  • •Review audit reports for accuracy and completeness and present findings to upper management.
  • •Collaborate with providers and conduct continuous educational training on appropriate billing patterns.
  • •Support legal actions, implement improvement opportunities for audit processes, and collaborate with medical management on medical policy and coding research.

Pay and Benefits

Salary: USD 87,700 - 157,800 annually
Perks:Health Insurance401kEquityPaid LeaveRemote Work

Key Requirements

  • •Bachelor’s degree in nursing or a related field (or equivalent experience).
  • •5+ years of medical coding and/or nursing experience.
  • •Strong medical terminology and research techniques, with knowledge of CPT code billing.
  • •Experience managing cross-functional teams or supervisory experience (hiring, training, assigning work, and managing performance).
  • •Clinical experience in hospital/clinic settings preferred; Certified Professional Coder, or RN/LPN a plus.
Experience:5+ years
Education:Bachelor's
Skills:LeadershipCollaborationAnalysisCommunicationStakeholder management
Certifications:Certified Professional Coder
Tech Stack:CPTMedical coding

Company Brief

Centene
Centene Corporation is a diversified, multinational healthcare enterprise that provides government-sponsored and commercial healthcare programs and services, specializing in Medicaid, Medicare, and specialty benefits management across the United States.
Industry: Health Insurance (Payers)
Company Size: Enterprise (1,001+ employees)
Revenue: USD 1B+
Growth: Public Company
Valuation: Public Company (Market Cap in USD)
Funding: IPO / Publicly Listed
Headquarters: St. Louis, United States
Founded: 1984
WebsiteLinkedIn