Clinical Investigator I (Special Investigation Unit)

Centene Corporation•Remote-MO, MO

3d•$56,200 - $101,000•Remote

About The Position

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 is a remote nationwide position. The ideal candidate is an RN or LPN with coding experience. Preferred experience in an insurance company, SIU, or fraud department. A strong fit would include experience reviewing medical records for fraud investigations. Physician office experience is preferred, especially in a specialist practice. Background in record review and documentation quality is highly valued. Documentation Improvement Specialist experience is also a strong match. The purpose of this role is to 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. This role will perform retrospective and prepayment reviews of medical records to identify potential abuse and fraud and inappropriate billing practices. The investigator will investigate, analyze, and identify provider billing patterns to recommend payment based on medical records, claim history, billing codes, regulatory and state guidelines, and policies. They will prepare a summary of findings and recommend next steps for providers. Additionally, they will identify preventative measures and recommend changes to internal policies and procedures and/or provider practices to prevent future fraudulent and erroneous practices. The investigator will consult with other investigators to identify abuse and fraud by utilizing clinical and coding expertise to analyze patterns in billing activities. The role also includes performing other duties as assigned and complying 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

RN or LPN with coding experience
Experience in an insurance company, SIU, or fraud department
Experience reviewing medical records for fraud investigations
Physician office experience, especially in a specialist practice
Background in record review and documentation quality
Documentation Improvement Specialist experience

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.
Perform other duties as assigned.
Comply with all policies and standards.