Coding Analyst I

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Coding Analyst I

USA-Montana-Great Falls

Position Purpose: Review high dollar claims for appropriate place of

service, length of stay, match to authorization, and possible outlier

DRG or Stop Loss pricing. Conduct complex business and operational

analyses to assure payments are in compliance with contract; identify

areas for improvement and clarification for better operational


* Work collaboratively with various cross-functional departments to

determine appropriateness of pricing

* Work collaboratively with Medical Management Department to

resolve any issues with medical review notes that affect high

dollar claim pricing

* Serve as a technical resource / coding subject matter expert for

contract pricing related issues

* Responsible for entire cycle of high dollar claims which includes

verifying information on submitted claims, reviewing contracts,

compliance guidelines, state regulations, eligibility, and

authorizations to determine reimbursement, and releasing claim for


* Identify key elements and processing requirements based on

diagnosis, provider, contracts and policies and procedures

utilizing broad based product or system knowledge to ensure timely

payments are generated.

* Conduct point of service review and resolution of high dollar

claims that are pending and/or adjusted incorrectly including

review, investigation, adjustment and resolution of claims, claims

appeals, inquiries, and inaccuracies in payment of claims.

* Collaborate with all departments to analyze complex claims issues

and special claim projects which are identified through high

dollar review

* Review inventories to determine appropriate task to complete

first and key performance indicators are met

* Manage and provide testing on new product or system configuration

to determine success rate of such product or configuration prior

to go-live

Education/Experience: : High school diploma or equivalent and 3+ years

of claims processing, medical billing, administrative, customer

service, call center, physician s office or other office services

experience. Previous managed care, State and/or Federal health care

programs (i.e., Medicaid, Medicare) or health insurance industry

experience. Knowledge of billing practices for hospitals, physicians

and/or ancillary providers as well as knowledge about contracting and

claims processing.

Licenses/Certifications: Registered Health Information Administrator

(RHIA), Registered Health Information Technician (RHIT), Certified

Coding Specialist (CSS), Professional Coder-Payer (CPC-P)

certification, Certified Professional Coder (CPC) or related

certifications preferred.

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.

Claims Operations

  • 1
  • Negotiable
  • None
  • None
  • Re-204973
  • Permanent
  • 0

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