Clinical Investigator I (Special Investigation Unit)

Centene Corporation•Remote-MO, MO

13d•Hybrid

About The Position

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.

Requirements

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

Associate's Degree related field or equivalent experience preferred
Provider education preferred
coding certification
nurse coding experience
experience with CPT coding

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.