Clinical Investigator, Behavioral Health

This is a fully remote position, open to applicants in Missouri.

📋 Description

• Perform thorough evaluations of medical records and documentation that support claims for providers, suppliers, and pharmacies, including those related to behavioral health care.

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

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

• Confirm authorization for services and ensure written documentation aligns with claim information.

• Guarantee the suitability and precision of diagnosis and procedure codes.

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

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

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

• Create reports detailing findings and recommendations.

• Articulate intricate audit findings during meetings and/or judicial hearings.

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

• Conduct retrospective and prepayment reviews to uncover fraud, waste, abuse, and improper billing practices.

• Examine and analyze provider billing patterns to establish payment accuracy.

• Compile findings summaries and suggest subsequent actions for providers.

• Identify preventive strategies and recommend changes to policies, procedures, and provider practices.

• Partner with investigators utilizing clinical and coding knowledge to assess billing activity patterns.

• Execute other assigned responsibilities while adhering to all policies and standards.

⛳️ Requirements

• A Master's Degree and 2 years of relevant experience are mandatory.

• A minimum of 2 years of clinical experience with an independent license is required.

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

• An active behavioral health license is required: LMHC, LCSW, LMFT, LPC, LMHP, or LIMHP.

• Experience in utilization management, auditing, and coding is preferred.

• Background in provider education and managed care organizations is preferred.

• Coding certification is preferred.

• Familiarity with medical records, claims, billing codes, regulatory and state guidelines, as well as CMS and state-specific coverage, limitations, and exclusion criteria is essential.

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

🏝️ Benefits

• Health insurance.

• 401K.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

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

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

• An equal opportunity employer committed to diversity.