Clinical Investigator Behavioral Health

This job is available in 18 remote locations: AZ, CO, FL, GA, IA, KY, MD, MI, MO, NC, NE, NV, OH, OK, PA, TX, WA, WI.

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. Provide investigative support to the Special Investigations Unit (SIU) related to coding and billing issues and identify potential overpayments and suspected health care fraud and abuse.

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, and 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, and assist SIU investigators during interviews, discussions, and negotiations with providers, suppliers, and pharmacies.

Responsibilities

• 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.
• Perform other duties as assigned and comply with all policies and standards.

Requirements

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

Preferred Qualifications

• Certified Professional Coder (CPC) certification.
• 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.
• Strong clinical documentation and problem-solving skills.
• Openness, adaptability, and flexibility for business changes.
• Strong communication, attention to detail, organizational, and time management skills.
• Skilled at utilizing Microsoft Office applications (MS 365 Co-Pilot, Excel, Outlook, Word, PowerPoint, OneNote, Teams).
• Openness to utilizing Generative AI tools (e.g., ChatGPT, Claude, Gemini, etc.).
• Comfortable presenting findings in a concise and effective manner to various stakeholders.
• Working knowledge of behavioral health billing and coding basics.

Pay

$56,200.00 - $101,000.00 per year. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives.

Benefits

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

Benefits may be subject to program eligibility.