[Hiring] Clinical Investigator Behavioral Health @Centene Corporation

Role Description

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.

***POSITION IS REMOTE***

***CANDIDATE MUST HAVE EXPERIENCE INVESTIGATING OR IDENTIFYING BEHAVIORAL HEALTH FRAUD, WASTE AND ABUSE TRENDS ***

Position Purpose:

• Conduct comprehensive reviews of medical records and documents supporting claims for providers, suppliers, and pharmacies.
• Provide investigative support to the Special Investigations Unit (SIU) related to coding and billing issues.
• Identify potential overpayments and suspected health care fraud and abuse.
• Verify authorization for services and written documentation of services provided against claim information.
• Ensure the appropriateness and accuracy of diagnosis and procedure codes supporting claims.
• Coordinate medical necessity and appropriate level of care determinations with Medical Directors.
• Validate services against CMS and State-specific coverage, limitations, and exclusion guidelines.
• Coordinate with internal and external resources to determine the appropriateness of codes found in records.
• Develop reports of findings and recommendations.
• Communicate complex results of 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 reviews of medical records to identify potential fraud, waste, and abuse.
• Investigate, analyze, and identify provider billing patterns to determine payment based on various guidelines.
• Prepare summary of findings and recommend next steps for providers.
• Identify preventative measures and recommend changes to internal policies and procedures.
• Collaborate with investigators to identify abuse and fraud by utilizing clinical and coding expertise.
• Perform other duties as assigned.
• Comply 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.