[Hiring] Clinical Investigator @Centene Corporation

Role Description

Conduct comprehensive reviews of medical records and documents supporting claims for providers, suppliers, and pharmacies, including but not limited to:

• Physicians
• Inpatient
• Outpatient
• Ancillary
• Behavioral health care
• Laboratory

Provides investigative support to the Special Investigations Unit (SIU) related to coding and billing issues, identifying potential overpayments and suspected health care fraud and abuse. Responsibilities include:

• Verifying authorization for services and written documentation of services provided against claim information.
• Ensuring the appropriateness and accuracy of diagnosis and procedure codes supporting claims.
• Coordinating medical necessity and appropriate level of care determinations with Medical Directors.
• Validating services against CMS and State-specific coverage, limitations, and exclusion guidelines.
• Coordinating with internal and external resources to determine the appropriateness of codes found in administrative, medical, claim, and financial records.
• Developing reports of findings and recommendations.
• Communicating complex results of audit findings in meetings and/or judicial hearings.
• Assisting SIU investigators during interviews, discussions, and negotiations with providers, suppliers, and pharmacies.

Key Details:

• This is a remote position.
• Candidates must hold an active behavioral health license.
• Experience in utilization management, auditing, and coding is preferred.

Additional responsibilities include:

• Performing retrospective and prepayment reviews of medical records to identify potential fraud, waste, and abuse and inappropriate billing practices.
• Investigating, analyzing, and identifying provider billing patterns to determine payment based on medical records, claim history, billing codes, regulatory and state guidelines, and policies.
• Preparing summary of findings and recommending next steps for providers.
• Identifying preventative measures and recommending changes to internal policies and procedures and/or provider practices to prevent future fraudulent and erroneous practices.
• Collaborating with investigators to identify abuse and fraud by utilizing clinical and coding expertise to analyze patterns in billing activities.
• Performing other duties as assigned.
• Complying with all policies and standards.

Qualifications

• Master’s Degree and 2 years of relevant experience required.
• 2+ years clinical experience with independent license required.
• 2 years of fraud, waste, and abuse experience required.
• Experience in provider education and managed care organization preferred.
• Coding certification preferred.

Requirements

• 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.

Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

Company Description

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.

Centene is an equal opportunity employer that is committed to diversity and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.