Clinical Investigator - Behavioral Health

Centene Corporation•Remote-MO, MO

5d•$56,200 - $101,000•Remote

About The Position

Centene is seeking a Clinical Investigator - Behavioral Health to conduct comprehensive reviews of medical records and documents supporting claims for providers, suppliers, and pharmacies. This role provides investigative support to the Special Investigations Unit (SIU) related to coding and billing issues, identifying potential overpayments and suspected healthcare fraud and abuse. The position requires verifying authorization for services, written documentation of services provided against claim information, ensuring the appropriateness and accuracy of diagnosis and procedure codes, coordinating medical necessity and level of care determinations with Medical Directors, and validating services against CMS and State-specific guidelines. The role involves coordinating with internal and external resources, developing reports of findings and recommendations, communicating complex results in meetings and/or judicial hearings, and assisting SIU investigators. The investigator will perform retrospective and prepayment reviews to identify potential fraud, waste, and abuse, analyze provider billing patterns, and identify preventative measures. Collaboration with investigators to identify abuse and fraud using clinical and coding expertise is essential. This is a remote position nationwide.

Requirements

Master’s Degree and 2 years of relevant experience required.
2+ years clinical experience with independent license required.
2 years of fraud, waste, and abuse experience required.
Behavioral health license - LMHC, LCSW, LMFT, LPC, LMHP, LIMHP

Nice To Haves

Experience in provider education and managed care organization preferred.
Coding certification preferred.

Responsibilities

Conduct comprehensive reviews of medical records and documents supporting claims for providers, suppliers, and pharmacies.
Provide investigative support to the Special Investigations Unit (SIU) related to coding and billing issues.
Identify potential overpayments and suspected healthcare fraud and abuse.
Verify authorization for services and written documentation of services provided against claim information.
Ensure the appropriateness and accuracy of diagnosis and procedure codes supporting claims.
Coordinate medical necessity and appropriate level of care determinations with Medical Directors.
Validate services against CMS and State-specific coverage, limitations, and exclusion guidelines.
Coordinate with internal and external resources in determining the appropriateness of codes found in administrative, medical, claim, and financial records.
Develop reports of findings and recommendations.
Communicate complex results of audit findings in meetings and/or judicial hearings.
Assist SIU investigators during interviews, discussions, and negotiations with providers, suppliers, and pharmacies.
Perform retrospective and prepayment reviews of medical records to identify potential fraud, waste, and abuse and inappropriate billing practices.
Investigate, analyze, and identify provider billing patterns to determine 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.
Collaborate with investigators to identify abuse and fraud by utilizing clinical and coding expertise to analyze patterns in billing activities.
Perform other duties as assigned.
Comply with all policies and standards.