Clinical Investigator Behavioral Health

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As a diversified, national organization, you’ll have access to competitive benefits, a fresh perspective on workplace flexibility, and an opportunity to transform the health of our 28 million members.

POSITION IS REMOTE.

CANDIDATE MUST HAVE EXPERIENCE INVESTIGATING OR IDENTIFYING BEHAVIORAL HEALTH FRAUD, WASTE AND ABUSE TRENDS.

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. Provide investigative

CCD support to the Special Investigations Unit (SIU) related to coding and billing issues, identify potential over payments and suspected health care fraud and abuse, verify authorization and documentation of services, ensure appropriate and accurate diagnosis and procedure codes, coordinate medical necessity and level of care determinations, and validate services against CMS and state‑specific coverage guidelines. Coordinate with internal and external resources, develop reports of findings, communicate complex audit results in meetings or judicial hearings, and assist SIU investigators during interviews and negotiations.

• 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 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.
• Perform other duties as assigned.
• Comply with all policies and standards.

Master’s Degree and at least 2 years of relevant experience required. 2+ years of clinical experience with an independent license required; 2 years of fraud, waste, and abuse experience required; experience in provider education and a managed‑care organization preferred; coding certification preferred.

Behavioral health license – LMHC, LCSW, LMFT, LPC, LMHP, LIMHP.

Pay Range: $56,200.00 – $ per year.

Centene offers a comprehensive benefits package including competitive pay, health insurance, 401(k) and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field, or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job‑related factors permitted by law, including Lied to part‑time status.

Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

Centene is an equal‑opportunity employer that is committed to diversity and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

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

Not Applicable.

Full‑time.

Research, Analyst, and Information Technology.

Hospitals and Health Care, Insurance.

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