Clinical Investigator Behavioral Health

About the role

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.

Responsibilities

• Verify authorization for services and written documentation of services provided against claim information
• Ensure the appropriateness and accuracy of diagnosis and procedure codes supporting such claims
• Coordinate medical necessity and appropriate level of care determinations with Medical Directors
• Validate services against CMS and State-specific coverage, limitations and exclusion guidelines
• Coordinate with internal and external resources in determining the appropriateness of codes found in administrative, medical, claim and financial records
• Develop reports of findings and recommendations
• Communicate complex results of audit findings in meetings and/or judicial hearings
• Assist SIU investigators during interviews, discussions and negotiations with providers, suppliers, and pharmacies
• Perform retrospective and prepayment reviews of medical records to identify potential fraud, waste, and abuse and inappropriate billing practices
• Investigate, analyze, and identify provider billing patterns to determine 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
• Collaborate with 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

Qualifications

• Master's Degree and 2+ years of direct board clinical behavioral health experience with a fully independent clinical license
• 2+ years of fraud, waste, and abuse experience
• Certified Professional Coder (CPC) certification preferred but not required
• Strong clinical documentation and problem-solving skills required
• Role requires openness, adaptability, and flexibility for business changes
• Strong communication, attention to detail, organizational and time management skills are required
• Skilled at utilizing Microsoft Office applications (MS 365 Co-Pilot, Excel, Outlook, Word, PowerPoint, OneNote, Teams) and is open to utilizing Generative AI tools (e.g. ChatGPT, Claude, Gemini, etc) is preferred
• Comfortable with presenting findings in a concise and effective manner to various stakeholders is required
• Working knowledge of behavioral health billing and coding basics preferred

Preferred experience

• 2+ years of experience in state agency investigations, special investigations in managed care, behavioral health provider reviews, medical record reviews, behavioral health billing/coding analysis, or behavioral health compliance
• 3+ years of providing direct Psychotherapy or Inpatient group therapy within inpatient psychiatric hospitals or units, residential treatment centers, substance abuse rehabilitation facilities, military or veteran hospitals
• Direct experience or working knowledge with FWA policies in state agency investigations or managed care investigations is preferred

License/Certification

One of the following Behavioral Health licenses is required: LMHC, LCSW, LMFT, LPC, LMHP, or LIMHP.

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, and a flexible approach to work with remote, hybrid, field or office work schedules.