Clinical Investigator – Behavioral Health

This is a fully remote position, open to applicants in Arizona, +10 more states.

📋 Description

• Conduct thorough evaluations of medical records and documentation related to provider, supplier, pharmacy, and behavioral health claims.

• Offer investigative assistance to the Special Investigations Unit regarding issues related to coding and billing.

• Detect potential overpayments and investigate suspected healthcare fraud and abuse.

• Confirm service authorizations and related documentation against claim details.

• Ensure the appropriateness and accuracy of diagnosis and procedure codes.

• Collaborate with Medical Directors on medical necessity and level-of-care assessments.

• Validate services against CMS and state-specific coverage, limitation, and exclusion criteria.

• Work with internal and external entities to ascertain code appropriateness in administrative, medical, claim, and financial documents.

• Generate reports detailing findings and recommendations.

• Present complex audit findings during meetings and judicial proceedings.

• Support SIU investigators in interviews, discussions, and negotiations with providers, suppliers, and pharmacies.

• Conduct retrospective and prepayment reviews of medical records.

• Investigate and analyze provider billing trends utilizing records, claim history, billing codes, regulations, state guidelines, and policies.

• Compile summaries of findings and suggest subsequent actions for providers.

• Identify preventative strategies and propose changes to policies, procedures, and provider practices.

• Collaborate with investigators to uncover fraud and abuse using clinical and coding expertise.

• Adhere to all relevant policies and standards.

• Execute additional tasks as assigned.

⛳️ Requirements

• Must be fully licensed with one approved Behavioral Health license upon application: LMHC, LCSW, LMFT, LPC, LMHP, or LIMHP.

• Possession of a Master’s Degree.

• Minimum of 2 years of direct board clinical behavioral health experience with a fully independent clinical license.

• A minimum of 2 years of experience related to fraud, waste, and abuse.

• Strong skills in clinical documentation and problem-solving.

• Willingness to adapt and remain flexible to business changes.

• Excellent communication, attention to detail, organizational, and time management abilities.

• Proficient in using Microsoft Office applications: MS 365 Co-Pilot, Excel, Outlook, Word, PowerPoint, OneNote, and Teams.

• Preference for familiarity with Generative AI tools such as ChatGPT, Claude, and Gemini.

• Comfortable presenting findings clearly and effectively to diverse stakeholders.

• Working knowledge of the basics of behavioral health billing and coding is preferred.

• CPC certification is preferred but not mandatory.

🏝️ Benefits

• Health insurance.

• 401K plan.

• Stock purchase options.

• Tuition reimbursement.

• Paid time off plus holidays.

• Flexible work arrangements including remote, hybrid, field, or office schedules.

• Additional incentives may be included in the total compensation package.