Centene Corporation
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.
Clinical Investigator, Behavioral Health
🕒 August 5
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Centene Corporation
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 • 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 service authorizations and documentation against claim information • Coordinate medical necessity and level-of-care determinations with Medical Directors • Validate services against CMS and state-specific coverage, limitations, and exclusion guidelines • Determine code appropriateness using 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 interviews, discussions, and negotiations • Perform retrospective and prepayment medical-record reviews • Investigate provider billing patterns and determine payment based on records, claim history, codes, regulations, 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, waste, and abuse using clinical and coding expertise • Perform other assigned duties and comply with policies and standards
🎯 Requirements
• Master’s Degree required • 2+ years of direct board clinical behavioral health experience required • Fully independent clinical license required; one of LMHC, LCSW, LMFT, LPC, LMHP, or LIMHP • 2+ years of fraud, waste, and abuse experience required • 2+ years preferred in state agency investigations, managed-care special investigations, behavioral health provider reviews, medical-record reviews, behavioral health billing/coding analysis, or behavioral health compliance • 3+ years preferred providing direct psychotherapy or inpatient group therapy in specified behavioral health facilities • Direct experience or working knowledge with FWA policies preferred • Strong clinical documentation and problem-solving skills required • Openness, adaptability, and flexibility for business changes • Strong communication, attention to detail, organization, and time-management skills required • Proficiency with Microsoft Office applications, including Excel, Outlook, Word, PowerPoint, OneNote, Teams, and MS 365 Co-Pilot preferred • Openness to using generative AI tools such as ChatGPT, Claude, or Gemini preferred • Ability to present findings concisely and effectively to various stakeholders required • Working knowledge of behavioral health billing and coding basics preferred • CPC certification preferred but not required
🏖️ Benefits
• Competitive pay • 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 • Incentives may be included in total compensation • Accommodation support for applicants
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