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Centene Corporation · 1 day ago

Clinical Investigator Behavioral Health

United States

Full-time

Remote

Entry, Mid Level

$56K/yr - $101K/yr

2+ years exp

Centene Corporation is transforming the health of communities, focusing on individualized care for its 28 million members. The Clinical Investigator Behavioral Health role involves conducting comprehensive reviews of medical records to investigate and identify fraud, waste, and abuse trends in behavioral health, while collaborating with various stakeholders to ensure compliance and accuracy in billing practices.

Hospital & Health Care

Responsibilities

Conduct comprehensive reviews of medical records and documents supporting claims for providers, suppliers, and pharmacies to include but not limited to physicians, inpatient, outpatient, ancillary, behavioral health care, laboratory, etc

Provides investigative support to the Special Investigations Unit (SIU) related to coding and billing issues and identifies potential overpayments and suspected health care fraud and abuse

Position requires the associate to verify authorization for services and written documentation of services provided against claim information, ensure the appropriateness and accuracy of diagnosis and procedure codes supporting such claims, coordinate medical necessity and appropriate level of care determinations with Medical Directors, and validate services against CMS and State-specific coverage, limitations and exclusion guidelines

Coordinate with internal and external resources in determining the appropriateness of codes found in administrative, medical, claim and financial records, develop reports of findings and recommendations, communicate complex results of audit findings in meetings and/or judicial hearings, and assist SIU investigators during interviews, discussions and negotiations with providers, suppliers, and pharmacies

Perform retrospective and prepayment reviews of medical records to identify potential fraud, waste, and abuse and inappropriate billing practices

Investigate, analyze, and identify provider billing patterns to determine payment based on medical records, claim history, billing codes, regulatory and state guidelines, and policies

Prepare summary of findings and recommend next steps for providers

Identify preventative measures and recommend changes to internal policies and procedures and/or provider practices to prevent future fraudulent and erroneous practices

Collaborate with investigators to identify abuse and fraud by utilizing clinical and coding expertise to analyze patterns in billing activities

Performs other duties as assigned

Complies with all policies and standards

Qualification

Behavioral health fraud investigationMedical record reviewCoding expertiseClinical experienceFraudWasteAbuse experienceProvider educationAnalytical skillsCommunication skillsCollaboration skills