Clinical Investigator, Behavioral Health

🔥 14 hours ago

🏰 Missouri – Remote

🏰 Missouri – Remote

💵 $56.2k - $101k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Centene Corporation

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1984

🛡️ Insurance

💼 Consulting

🏥 Healthcare

Insurance • Consulting • Healthcare

Centene Corporation is a leading provider of government-sponsored healthcare services, specializing in delivering affordable and high-quality healthcare solutions. For over 40 years, Centene has focused on transforming the health of communities by expanding access to Medicaid, Medicare, and Health Insurance Marketplace services, as well as serving military communities through the TRICARE program. As the largest Medicaid managed care organization and a key participant in the Marketplace, Centene emphasizes localized healthcare delivery combined with strong partnerships with nonprofit organizations to meet the unique needs of its members. Centene is also committed to corporate sustainability and social responsibility, prioritizing environmental stewardship and ethical governance to enhance the well-being of the communities it serves.

📋 Description

• Conduct comprehensive reviews of medical records and documents supporting claims for providers, suppliers, and pharmacies, including behavioral health care • Provide investigative support to the Special Investigations Unit related to coding and billing issues • Identify potential overpayments and suspected health care fraud and abuse • Verify authorization for services and written documentation against claim information • Ensure the appropriateness and accuracy of diagnosis and procedure codes • 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 to determine code appropriateness in administrative, medical, claim, and financial records • Develop reports of findings and recommendations • Communicate complex 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 to identify fraud, waste, abuse, and inappropriate billing practices • Investigate and analyze provider billing patterns to determine payment • Prepare findings summaries and recommend next steps for providers • Identify preventative measures and recommend policy, procedure, and provider-practice changes • Collaborate with investigators using clinical and coding expertise to analyze billing activity patterns • Perform other assigned duties and comply with all policies and standards

🎯 Requirements

• 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 • Active behavioral health license required: LMHC, LCSW, LMFT, LPC, LMHP, or LIMHP • Experience in utilization management, auditing, and coding preferred • Experience in provider education and managed care organization preferred • Coding certification preferred • Knowledge of medical records, claims, billing codes, regulatory and state guidelines, CMS and State-specific coverage, limitations and exclusion guidelines • Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

🏖️ Benefits

• Health insurance • 401K • Stock purchase plans • Tuition reimbursement • Paid time off plus holidays • Flexible approach to work with remote, hybrid, field or office work schedules • Additional forms of incentives may be included in total compensation • Equal opportunity employer committed to diversity