Clinical Investigator, Behavioral Health

This is a fully remote position, open to applicants in Arizona, +5 more states.

📋 Description

• Conduct thorough evaluations of medical records and documents that support claims for providers, suppliers, pharmacies, and various healthcare services.

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

• Detect potential overpayments and suspected instances of healthcare fraud and abuse.

• Confirm service authorizations and written documentation against claim data.

• Ensure that diagnosis and procedure codes backing claims are both suitable and accurate.

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

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

• Work with internal and external resources to assess code appropriateness in administrative, medical, claim, and financial records.

• Generate reports detailing findings and recommendations.

• Present complex audit findings during meetings and/or judicial hearings.

• Assist SIU investigators during interviews, discussions, and negotiations with providers, suppliers, and pharmacies.

• Conduct retrospective and prepayment medical record evaluations to uncover fraud, waste, abuse, and improper billing practices.

• Analyze provider billing patterns to ascertain payment based on records, claims, codes, regulations, guidelines, and policies.

• Prepare summaries of findings and advise on next steps for providers.

• Identify preventative measures and suggest modifications to policies, procedures, and/or provider practices.

• Collaborate with investigators to detect abuse and fraud utilizing clinical and coding knowledge.

• Perform additional tasks as assigned.

• Adhere to all policies and standards.

⛳️ Requirements

• Candidates must hold a valid license from one of the approved licensing bodies upon submitting the Centene application.

• A Master’s Degree is required.

• At least 2 years of direct board clinical behavioral health experience with a fully independent clinical license is necessary.

• A minimum of 2 years of experience in fraud, waste, and abuse is required.

• One of the following Behavioral Health licenses is required: LMHC, LCSW, LMFT, LPC, LMHP, or LIMHP.

• Preferred: 2+ years of experience in state agency investigations, special investigations in managed care, behavioral health provider reviews, medical record reviews, behavioral health billing/coding analysis, or behavioral health compliance.

• Preferred: 3+ years of direct Psychotherapy or Inpatient group therapy experience in specified inpatient, residential, rehabilitation, military, or veteran healthcare settings.

• Preferred: Direct experience or working knowledge of FWA policies in state agency investigations or managed care investigations.

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

• A willingness to be open, adaptable, and flexible to business changes is important.

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

• Proficiency in Microsoft Office applications, including MS 365 Co-Pilot, Excel, Outlook, Word, PowerPoint, OneNote, and Teams; openness to Generative AI tools is preferred.

• Comfortable presenting findings succinctly and effectively to a variety of stakeholders.

• Preferred: Working knowledge of behavioral health billing and coding fundamentals.

• CPC certification is preferred but not mandatory.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K plan.

• Stock purchase plans.

• Tuition reimbursement opportunities.

• Paid time off in addition to holidays.

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

• Other forms of incentives may be included in total compensation.

• Equal opportunity employer dedicated to diversity.