Clinical Validation Appeal Jobs (NOW HIRING)

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.

Remote Role: Minimum experience required: 6+ years Performing MS-DRG and APR-DRG coding experience and 3+ years Conducting DRG reviews for a Payment Integrity vendor or payer.

Position Purpose:
Supervise and coordinate the day-to-day activities of the Coding & Clinical Review team within Payment Integrity, ensuring accurate diagnosis-related group assignment, clinical validation, and audit outcomes in alignment with established policies, regulatory requirements, and organizational objectives. This role executes strategies and initiatives established by leadership while driving team performance, quality, operational efficiency, and consistent application of coding and clinical review standards. The position may oversee diagnosis-related group audit, Quality Assurance, Readmissions, Appeals, or broader operational teams and serves as a subject matter expert for complex coding, clinical validation, and audit-related matters. This role also adheres to and promotes American Health Information Management Association Code of Ethics and professional standards.

• Supervise and coordinate daily work activities of Coding & Clinical Review staff to ensure timely and accurate completion of DRG audit, QA, readmissions, appeals, and/or operational workflows
• Monitor and evaluate team performance against established productivity, quality, and service level expectations; take appropriate action to address gaps
• Provide guidance and direction on coding, clinical validation, and audit determinations in accordance with ICD-10-CM/PCS guidelines, DRG methodologies, and applicable payer and regulatory policies
• Review and resolve complex or escalated cases; elevate high-risk issues to management as appropriate
• Implement and support departmental policies, procedures, and program initiatives to ensure consistent execution of Payment Integrity strategies
• Conduct quality assurance activities including audits, calibration sessions, and inter-rater reliability reviews to ensure consistency and accuracy of determinations
• Support appeals processes by reviewing clinical documentation, validating determinations, and guiding response development
• Analyze operational and audit data to identify trends, variances, and improvement opportunities; communicate findings to management
• Ensure compliance with regulatory requirements, internal policies, payer guidelines, and AHIMA ethical standards; reinforce a culture of integrity and accountability
• Collaborate with cross-functional partners (e.g., Medical Directors, Provider Relations, Compliance, Appeals) to address issues and improve outcomes
• Assist with staff selection, onboarding, training, and workforce planning
• Participate in and support process improvement efforts to enhance efficiency, quality, and financial performance
• Performs other duties as assigned
• Complies with all policies and standards

Education/Experience:
Associate's Degree in Health Information Management, Nursing, or related field required
6+ years Performing MS-DRG and APR-DRG coding experience required
3+ years Conducting DRG reviews for a Payment Integrity vendor or payer experience required
3+ years DRG encoder/grouper experience (TruCode/TruBridge, 3M, Optum Encoder, Webstrat, PSI, or similar) experience required
1+ years Inpatient hospital documentation improvement, complex appeal/dispute review, or auditor education/training experience preferred
Licenses/Certifications:
RHIT - Registered Health Information Technician required or:
CCS-Certified Coding Specialist required or: (CIC) required or

Certified Clinical Documentation Specialist (CCDS) required or: RN - Registered Nurse - State Licensure and/or Compact State Licensure Registered Nurse (in combination with a coding credential) preferred

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