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By | April 13, 2022

Job Responsibilities : Clinical Reviewer

Salary : $15 per hour

Company : Centene Corporation

Location : Remote US


  • Perform complex retrospective and prepayment reviews of medical records to identify potential abuse and fraud and inappropriate billing practices. Responsible for second level appeals reviews
  • Investigate analyze and identify provider billing patterns to recommend payment based on medical records claim history billing codes regulatory and state guidelines and policies
  • Prepare summary of findings and recommend next steps for providers
  • Identify preventative measures and recommend changes to internal policies and procedures and/or provider practices to prevent future fraudulent and erroneous practices
  • Consult investigators to identify abuse and fraud by utilizing clinical and coding expertise to analyze patterns in billing activities
  • Perform onsite audits in conjunction with investigators and/or managers. Review providers’ claims history licensure and specialty. Assess providers by interviewing staff examining the facility and equipment and reviewing medical records
  • Provide instructions to the claims department for prepayment reviews
  • Assist SIU Clinical Supervisor/Manager as needed with training new hires answering questions from Clinical Reviewer I employees auditing work of junior-level employees assisting with provider education and answering questions from investigators
  • Our Comprehensive Benefits Package

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