Clinical Investigator Behavioral Health

Centene Corporation

1d • Remote

About The Position

Centene is seeking a Clinical Investigator Behavioral Health to join their team. This role is responsible for conducting comprehensive reviews of medical records and documents to identify potential fraud, waste, and abuse. The investigator will support the Special Investigations Unit (SIU) by analyzing coding and billing issues, verifying services, and ensuring accuracy of diagnosis and procedure codes. This position requires collaboration with various internal and external resources, including Medical Directors and SIU investigators, to determine the appropriateness of services and codes. The investigator will perform retrospective and prepayment reviews, analyze provider billing patterns, and prepare reports of findings and recommendations. Additionally, the role involves identifying preventative measures and collaborating with investigators to detect fraud and abuse using clinical and coding expertise. The position is remote and requires experience in investigating behavioral health fraud, waste, and abuse trends.

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.
• Candidate MUST HAVE EXPERIENCE INVESTIGATING OR IDENTIFYING BEHAVIORAL HEALTH FRAUD, WASTE AND ABUSE TRENDS.

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.
• Provides investigative support to the Special Investigations Unit (SIU) related to coding and billing issues.
• Identifies potential overpayments and suspected health care fraud and abuse.
• Verifies authorization for services and written documentation of services provided against claim information.
• Ensures the appropriateness and accuracy of diagnosis and procedure codes supporting claims.
• Coordinates medical necessity and appropriate level of care determinations with Medical Directors.
• Validates services against CMS and State-specific coverage, limitations and exclusion guidelines.
• Coordinates with internal and external resources in determining the appropriateness of codes found in administrative, medical, claim and financial records.
• Develops reports of findings and recommendations.
• Communicates complex results of audit findings in meetings and/or judicial hearings.
• Assists SIU investigators during interviews, discussions and negotiations with providers, suppliers, and pharmacies.
• Performs retrospective and prepayment reviews of medical records to identify potential fraud, waste, and abuse and inappropriate billing practices.
• Investigates, analyzes, and identifies provider billing patterns to determine payment based on medical records, claim history, billing codes, regulatory and state guidelines, and policies.
• Prepares summary of findings and recommends next steps for providers.
• Identifies preventative measures and recommends changes to internal policies and procedures and/or provider practices to prevent future fraudulent and erroneous practices.
• Collaborates 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.

Benefits

• competitive pay
• health insurance
• 401K and stock purchase plans
• tuition reimbursement
• paid time off plus holidays
• a flexible approach to work with remote, hybrid, field or office work schedules.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level