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. This position is remote nationwide. Ideal candidate will be RN or LPN with coding experience, preferably someone who has worked for an insurance company in a Special Investigations Unit (SIU) or fraud department. Ideal background includes reviewing medical records for fraud investigations, as well as experience from a specialist physician’s office focused on record review and documentation quality. Experience as a Documentation Improvement Specialist is also a strong fit. 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
• 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

Nice To Haves

• Provider education preferred
• Ideal candidate will be RN or LPN with coding experience, preferably someone who has worked for an insurance company in a Special Investigations Unit (SIU) or fraud department.
• Ideal background includes reviewing medical records for fraud investigations, as well as experience from a specialist physician’s office focused on record review and documentation quality.
• Experience as a Documentation Improvement Specialist is also a strong fit.

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.

Benefits

• Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules.
• Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status.
• Total compensation may also include additional forms of incentives.
• Benefits may be subject to program eligibility.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees