Clinical Investigator – Behavioral Health

🔥 0 minutes ago

🐊 Florida, Kansas, +2 more states – Remote

🐊 Florida – Remote 🌪️ Kansas – Remote 🏈 Ohio – Remote 🏰 Missouri – Remote

💵 $56.2k - $101k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

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Centene Corporation

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1984

⚕️ Healthcare Insurance

🤝 Non-profit

🌍 Social Impact

Healthcare Insurance • Non-profit • Social Impact

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 • Provides investigative support to the Special Investigations Unit (SIU) related to coding and billing issues • Identifies potential overpayments and suspected health care fraud and abuse • Verifies authorization for services and written documentation of services provided against claim information • Ensures the appropriateness and accuracy of diagnosis and procedure codes supporting such claims • Coordinates medical necessity and appropriate level of care determinations with Medical Directors • Validates services against CMS and State-specific coverage, limitations and exclusion guidelines • Coordinates with internal and external resources to determine the appropriateness of codes • Develops reports of findings and recommendations • Communicates complex results of audit findings in meetings and/or judicial hearings • Assists SIU investigators during interviews, discussions and negotiations • Performs retrospective and prepayment reviews of medical records to identify potential fraud, waste, and abuse • Investigates, analyzes, and identifies provider billing patterns • Prepares summary of findings and recommends next steps for providers • Identifies preventative measures and recommends changes to internal policies and procedures and/or provider practices

🎯 Requirements

• Master's Degree • 2 years of relevant experience required • 2+ years fraud, waste and abuse experience required • 2 years clinical experience with independent license required • experience in provider education and managed care organization preferred • coding certification preferred • Behavioral health license - LMHC, LCSW, LMFT, LPC, LMHP, LIMHP

🏖️ 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