Clinical Investigator I (Special Investigation Unit)

Centene Corporation

3d•Remote

About The Position

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. POSITION IS REMOTE IDEAL CANDIDATE WILL HAVE CPC OR CPMA CERTIFICATION Position Purpose: Audit medical records to identify inappropriate billing practices and recommend next steps through extensive review of claims data, medical records, corporate policy, state/federal policy, and practice standards. Perform retrospective and prepayment reviews of medical records to identify potential abuse and fraud and inappropriate billing practices 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 Performs other duties as assigned. Complies with all policies and standards.

Requirements

Associate's Degree related field or equivalent experience preferred
2+ years related clinical experience in the field of obtained license required
Provider education preferred
Coding certification from an accredited organization (American Academy of Professional Coders or American Health Information Management Association), RN, LPC, LPN, LCSW, LMHC, PT, OT, or ST or related license. required

Responsibilities

Audit medical records to identify inappropriate billing practices and recommend next steps through extensive review of claims data, medical records, corporate policy, state/federal policy, and practice standards.
Perform retrospective and prepayment reviews of medical records to identify potential abuse and fraud and inappropriate billing practices
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
Performs other duties as assigned.
Complies with all policies and standards.