Clinical Investigator, Behavioral Health

Centene Corporation

. Conduct comprehensive reviews of medical records and documents supporting claims for providers, suppliers, and pharmacies, including behavioral health care .

Posted 10/13/2026full-timeRemote • Missouri • United StatesJuniorMid-Level💰 $56,200 - $101,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical record review, coding accuracy, and fraud detection, with a strong focus on compliance with CMS and state-specific guidelines. Capable of conducting audits, developing reports, and communicating findings effectively in various settings.

Highest-signal resume keywords

Master’s DegreeClinical ExperienceFraud, Waste, And Abuse ExperienceActive Behavioral Health LicenseCoding Certification

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Record ReviewCoding AccuracyFraud DetectionUtilization ManagementAuditingBilling Code KnowledgeClaims AnalysisReport DevelopmentProvider EducationPolicy Recommendation

Soft Skills

CommunicationCollaborationAnalytical ThinkingProblem SolvingNegotiation

Certifications & Qualifications

Active Behavioral Health LicenseCoding Certification

Industry Keywords

CMS GuidelinesState-Specific CoverageBilling PracticesHealth Care FraudBehavioral Health Care

About the role

Key responsibilities & impact

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

What you’ll need

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

Comp & perks

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