Clinical Investigator, Behavioral Health

This is a fully remote position, open to applicants in Arizona, +3 more states.

📋 Description

• Execute thorough evaluations of medical records and documents that substantiate claims for providers, suppliers, and pharmacies.

• Offer investigative assistance to the Special Investigations Unit concerning coding and billing discrepancies.

• Detect potential overpayments and suspected instances of health care fraud and abuse.

• Confirm service authorizations and documentation against claim details.

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

• Validate services in accordance with CMS and state-specific coverage, limitations, and exclusion criteria.

• Assess code appropriateness by reviewing administrative, medical, claim, and financial records.

• Create reports detailing findings and recommendations.

• Articulate complex audit results during meetings and judicial proceedings.

• Support SIU investigators during interviews, discussions, and negotiations.

• Conduct retrospective and prepayment medical record assessments.

• Analyze provider billing trends and establish payment based on records, claim history, codes, regulations, and policies.

• Compile summaries of findings and propose subsequent steps for providers.

• Identify preventive strategies and suggest modifications to policies, procedures, and provider practices.

• Collaborate with investigators to uncover fraud, waste, and abuse utilizing clinical and coding expertise.

• Carry out other assigned responsibilities while adhering to policies and standards.

⛳️ Requirements

• A Master’s Degree is mandatory.

• A minimum of 2 years of direct board clinical behavioral health experience is required.

• A fully independent clinical license is necessary; candidates must hold one of the following: LMHC, LCSW, LMFT, LPC, LMHP, or LIMHP.

• At least 2 years of experience in fraud, waste, and abuse is required.

• A minimum of 2 years is preferred in state agency investigations, managed-care special investigations, behavioral health provider evaluations, medical record reviews, behavioral health billing/coding analysis, or behavioral health compliance.

• 3 or more years of experience is preferred in providing direct psychotherapy or inpatient group therapy in designated behavioral health facilities.

• Direct experience or familiarity with FWA policies is preferred.

• Strong clinical documentation and problem-solving abilities are essential.

• A willingness to be open, adaptable, and flexible in response to business changes is required.

• Excellent communication, attention to detail, organizational, and time-management skills are necessary.

• Proficiency in Microsoft Office applications, including Excel, Outlook, Word, PowerPoint, OneNote, Teams, and MS 365 Co-Pilot is preferred.

• Openness to utilizing generative AI tools such as ChatGPT, Claude, or Gemini is preferred.

• The ability to present findings clearly and effectively to various stakeholders is required.

• A working knowledge of basic behavioral health billing and coding is preferred.

• CPC certification is preferred but not mandatory.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement opportunities.

• Paid time off in addition to holidays.

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

• Potential for incentives to be included in overall compensation.

• Accommodation support for applicants.