Clinical Investigator, Behavioral Health

🔥 12 hours ago

🌵 Arizona, Florida, +4 more states – Remote

🌵 Arizona – Remote 🐊 Florida – Remote 🌾 Iowa – Remote 🚗 Michigan – Remote 🏰 Missouri – Remote 🤠 Texas – 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.

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

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, pharmacies, and various healthcare services • Provide investigative support to the Special Investigations Unit related to coding and billing issues • Identify potential overpayments and suspected healthcare fraud and abuse • Verify service authorizations and written documentation against claim information • Ensure diagnosis and procedure codes supporting claims are appropriate and accurate • Coordinate medical necessity and level-of-care determinations with Medical Directors • Validate services against CMS and state-specific coverage, limitation, 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 medical-record reviews to identify fraud, waste, abuse, and inappropriate billing practices • Investigate and analyze provider billing patterns to determine payment based on records, claims, codes, regulations, guidelines, and policies • Prepare summaries of findings and recommend next steps for providers • Identify preventive measures and recommend policy, procedure, and/or 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

• Candidates must be fully licensed with one of the approved licenses upon submission of the Centene application • Master’s Degree required • 2+ years of direct board clinical behavioral health experience with a fully independent clinical license • 2+ years of fraud, waste, and abuse experience required • One required Behavioral Health license: LMHC, LCSW, LMFT, LPC, LMHP, or LIMHP • 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 preferred • 3+ years of direct Psychotherapy or Inpatient group therapy experience in specified inpatient, residential, rehabilitation, military, or veteran healthcare settings preferred • Direct experience or working knowledge with FWA policies in state agency investigations or managed care investigations preferred • 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 in Microsoft Office applications, including MS 365 Co-Pilot, Excel, Outlook, Word, PowerPoint, OneNote, and Teams; openness to Generative AI tools preferred • Comfortable presenting findings concisely and effectively to various stakeholders • Working knowledge of behavioral health billing and coding basics preferred • CPC certification preferred but not required

🏖️ 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 • Additional forms of incentives may be included in total compensation • Equal opportunity employer committed to diversity