Clinical Investigator – Behavioral Health

🔥 1 hour ago

🌲 North Carolina, Missouri – Remote

🌲 North Carolina – Remote 🏰 Missouri – Remote

💵 $56.2k - $101k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 0%

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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 provider, supplier, pharmacy, and behavioral health claims • Provide investigative support to the Special Investigations Unit on coding and billing issues • Identify potential overpayments and suspected healthcare fraud, waste, and abuse • Verify service authorizations and documentation against claim information • Ensure the appropriateness and accuracy of diagnosis and procedure codes • Coordinate medical necessity and 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 results in meetings and/or judicial hearings • Assist SIU investigators during provider, supplier, and pharmacy interviews, discussions, and negotiations • Perform retrospective and prepayment medical-record reviews • Investigate and analyze provider billing patterns to determine payment • Prepare findings summaries and recommend next steps for providers • Identify preventive measures and recommend policy, procedure, and provider-practice changes • Collaborate with investigators to identify abuse and fraud using clinical and coding expertise • Perform other duties as assigned • Comply with all policies and standards

🎯 Requirements

• Master’s Degree required • 2 years of relevant experience required • 2+ years clinical experience with independent license required • 2 years of fraud, waste, and abuse experience required • Behavioral health license required: LMHC, LCSW, LMFT, LPC, LMHP, or LIMHP • Experience in provider education and managed care organization preferred • Coding certification preferred • Ability to conduct comprehensive medical-record and claims reviews • Knowledge of coding and billing issues, medical necessity, level-of-care determinations, CMS and state-specific coverage guidelines • Ability to analyze billing patterns, claim history, billing codes, regulatory and state guidelines, and policies • Ability to communicate complex audit findings in meetings and/or judicial hearings • Applicants must be able to work remotely from anywhere within the United States • Availability to work Monday through Friday

🏖️ Benefits

• Competitive pay • Health insurance • 401K plan • Stock purchase plans • Tuition reimbursement • Paid time off plus holidays • Flexible approach to work with remote, hybrid, field or office work schedules • Equal opportunity employer committed to diversity