Clinical Policy Coding Analyst

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. 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 Position Purpose: Provides support to Clinical Policy to ensure accuracy of coding of Clinical Coverage Guidelines (CCGs) and Claims Edit Guidelines (CEGs) and maintains authorization management tools. Participates in cross-functional efforts related to claims payment policy edit changes based on clinical, financial and claims operations perspective. Provides support to the departments across the organization as well as within Health Services regarding Clinical Policy and Procedures, governing committees, enterprise utilization management strategy, clinical effectiveness initiatives, and Authorization Rules. Supports the Chief Medical Director of Medical Management with the evaluation escalated disputes (and conduct necessary research) as well as review and response to complex medical coding and payment policy inquiries. Directs the initial review of coding in Clinical Coverage Guidelines (CCGs) to support the Medical Management Team by reviewing and updating evidence based clinical policy (and related coding rules and regulations) to support medical necessity reviews for authorization requests. Leads revisions to Claims Edit Guidelines (CEGs) as well as development of new CEGs. Includes in depth research of State and Federal Regulations, coding industry guidelines, and other related WellCare policies. Conducts research involving consistent evidence-based criteria and authorization rules in support of clinical dec