Clinical Investigator – Behavioral Health

🔥 0 minutes ago

🌵 Arizona, Florida, +9 more states – Remote

🌵 Arizona – Remote 🐊 Florida – Remote 🌾 Iowa – Remote 🌪️ Kansas – Remote ⚜️ Louisiana – Remote 🌶️ New Mexico – Remote 🌲 North Carolina – Remote 🌪️ Oklahoma – Remote 🚗 Michigan – Remote 🏰 Missouri – Remote 🤠 Texas – 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 regarding coding and billing issues • Identify potential overpayments and suspected healthcare fraud and abuse • Verify service authorizations and documentation against claim information • Ensure diagnosis and procedure code appropriateness and accuracy • 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 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 using records, claim history, billing codes, regulations, state guidelines, and policies • Prepare findings summaries and recommend next steps for providers • Identify preventative measures and recommend policy, procedure, and provider-practice changes • Collaborate with investigators to identify fraud and abuse using clinical and coding expertise • Comply with all policies and standards • Perform other duties as assigned

🎯 Requirements

• Fully licensed with one approved Behavioral Health license upon submission: LMHC, LCSW, LMFT, LPC, LMHP, or LIMHP • Master’s Degree • 2+ years of direct board clinical behavioral health experience with a fully independent clinical license • 2+ years of fraud, waste, and abuse experience • 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, and Teams • Open to utilizing Generative AI tools such as ChatGPT, Claude, and Gemini 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

• 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