Clinical Investigator, Behavioral Health
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Job Description
Clinical Investigator reviewing behavioral-health claims and billing patterns for Centene. Supporting SIU investigations into fraud, waste, abuse, coding, and overpayments.
Responsibilities:
- Conduct comprehensive reviews of medical records and documents supporting claims for providers, suppliers, and pharmacies, including behavioral health care
- Provide investigative support to the Special Investigations Unit related to coding and billing issues
- Identify potential overpayments and suspected health care fraud and abuse
- Verify authorization for services and written documentation against claim information
- Ensure the appropriateness and accuracy of diagnosis and procedure codes
- 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 code appropriateness in administrative, medical, claim, and financial records
- Develop reports of findings and recommendations
- Communicate complex 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 to identify fraud, waste, abuse, and inappropriate billing practices
- Investigate and analyze provider billing patterns to determine payment
- Prepare findings summaries and recommend next steps for providers
- Identify preventative measures and recommend policy, procedure, and provider-practice changes
- Collaborate with investigators using clinical and coding expertise to analyze billing activity patterns
- Perform other assigned duties and comply with all policies and standards
Requirements:
- 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
- Active behavioral health license required: LMHC, LCSW, LMFT, LPC, LMHP, or LIMHP
- Experience in utilization management, auditing, and coding preferred
- Experience in provider education and managed care organization preferred
- Coding certification preferred
- Knowledge of medical records, claims, billing codes, regulatory and state guidelines, CMS and State-specific coverage, limitations and exclusion guidelines
- Qualified 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 approach to work with remote, hybrid, field or office work schedules
- Additional forms of incentives may be included in total compensation
- Equal opportunity employer committed to diversity
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