Clinical Investigator - Behavioral Health

Position Purpose

Conduct comprehensive reviews of medical records and documents supporting claims for providers, suppliers, and pharmacies to include but not limited to physicians, inpatient, outpatient, ancillary, behavioral health care, laboratory, etc. Provides investigative support to the Special Investigations Unit (SIU) related to coding and billing issues and identifies potential overpayments and suspected health care fraud and abuse.

Position Requirements

• Verifies authorization for services and written documentation of services provided against claim information
• Ensures the appropriateness and accuracy of diagnosis and procedure codes supporting such claims
• Coordinates medical necessity and appropriate level of care determinations with Medical Directors
• Validates services against CMS and State-specific coverage, limitations and exclusion guidelines
• Coordinates with internal and external resources in determining the appropriateness of codes found in administrative, medical, claim and financial records
• Develops reports of findings and recommendations
• Communicates complex results of audit findings in meetings and/or judicial hearings
• Aids SIU investigators during interviews, discussions and negotiations with providers, suppliers, and pharmacies
• Performs retrospective and prepayment reviews of medical records to identify potential fraud, waste, and abuse and inappropriate billing practices
• Investigates, analyzes, and identifies provider billing patterns to determine payment based on medical records, claim history, billing codes, regulatory and state guidelines, and policies
• Prepares summary of findings and recommends next steps for providers
• Identifies preventative measures and recommends changes to internal policies and procedures and/or provider practices to prevent future fraudulent and erroneous practices
• Collaborates with investigators to identify abuse and fraud by utilizing clinical and coding expertise to analyze patterns in billing activities

Qualifications

• Master’s Degree and 2 years of relevant experience required
• 2+ years clinical experience with independent license required
• 2 years of fraud, waste, and abuse experience required
• Experience in provider education and managed care organization preferred
• Coding certification preferred

Skills

• Strong analytical and problem-solving skills
• Excellent communication and interpersonal skills
• Ability to work independently and as part of a team
• Proficient in coding and billing systems
• Knowledge of healthcare regulations and compliance

Pay

$56,200.00 - $101,000.00 per year

Benefits

• Competitive pay
• Health insurance
• 401K and stock purchase plans
• Tuition reimbursement
• Paid time off plus holidays
• A flexible approach to work with remote, hybrid, field or office work schedules

Centene Values

• Diversity
• Inclusion
• Ethics
• Integrity