Clinical Investigator (Behavioral Health)

Centene Corporation•Remote-MO, MO

3d•$56,200 - $101,000•Remote

About The Position

Conduct comprehensive reviews of medical records and documents supporting claims for providers, suppliers, and pharmacies to include but not limited to physicians, inpatient, outpatient, ancillary, behavioral health care, laboratory, etc. Provides investigative support to the Special Investigations Unit (SIU) related to coding and billing issues and identifies potential overpayments and suspected health care fraud and abuse. Position requires the associate to verify authorization for services and written documentation of services provided against claim information, ensure the appropriateness and accuracy of diagnosis and procedure codes supporting such claims, coordinate medical necessity and appropriate level of care determinations with Medical Directors, and 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, and assist SIU investigators during interviews, discussions and negotiations with providers, suppliers, and pharmacies.

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.
Active behavioral health license required.

Nice To Haves

Experience in utilization management, auditing, and coding is preferred.
Experience in provider education and managed care organization preferred.
Coding certification preferred.

Responsibilities

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.
Performs other duties as assigned.
Complies with all policies and standards.