Clinical Investigator

Remote within the United States, preferably in Pennsylvania, to conduct provider on-site visits. For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required.

About the role

The Clinical Investigator is responsible for performing comprehensive clinical investigations and reporting to identify, investigate, and correct fraudulent and/or abusive billing and coding practices. This includes reviewing and analyzing medical records and other documentation to determine the accuracy and appropriateness of billing for documented services, such as:

• Assessing the appropriateness of services with respect to the member's behavioral health condition
• Evaluating the accuracy of coding compared to medical records
• Documenting rationale for review decisions

This position manages a caseload from receipt of referral through case resolution, resulting in preparation of all documentation for further investigation.

Responsibilities

• Provide clinical investigation analysis and reporting using specialized analytical skills and knowledge with internal and external data systems
• Identify systemic issues of fraud, waste, and/or abuse within areas of job responsibilities for the AmeriHealth Caritas Family of Companies
• Coordinate with PerformCare Claims, Finance, and other departments regarding overpayments and case development
• Produce and develop case reporting as deliverables to designated LOB Oversights and others as appropriate; update case tracking system with all case actions and follow-up
• Make referrals to BPI, the OAG, and others if deemed appropriate based on case development
• Assist with coordination of recovery of overpayments related to fraudulent and/or abusive billing and coding practices
• Provide education related to coding, medical record documentation requirements, and government-funded healthcare compliance, fraud, waste, and abuse to Health Plan staff, vendors, and contracted providers/facilities
• Participate in clinical Fraud, Waste, and Abuse measurement projects, help develop enhanced clinical analysis data systems, and serve as a resource for developing investigative results and solutions
• Interface with providers and conduct on-site audits

Requirements

• Master's Degree required in psychology, social work, or related field
• Experience in providing direct service or involvement in Behavioral Health
• Licensure preferred: LSW, LCSW, or LPC
• Accredited Health Care Fraud Examiner (AHFI) and/or Certified Insurance Fraud Investigator (CIFI) preferred or willing to obtain within one year of employment

Skills

• Experience with BH-MCOs preferred
• Knowledge of and experience working in various Behavioral Health levels of care
• Practical experience in the use of computerized databases
• Familiarity with claims payment, coding, and reimbursement methodologies
• Ability to make decisions with supporting documentation independently, combined with team and leadership interactions
• Ability to work collaboratively with assigned line of business, County Oversight entities, providers, BPI, OMHSAS, and others
• Excellent verbal and written communication skills with strong research skills
• Experience using Microsoft Excel and data mining different data sets

Benefits

• Flexible work solutions including remote options and hybrid work schedules
• Competitive pay
• Paid time off including holidays and volunteer events
• Health insurance coverage for you and your dependents on Day 1
• 401(k)
• Tuition reimbursement