Clinical Investigator, Behavioral Health

Centene Corporation

. Conduct comprehensive reviews of medical records and documents supporting claims for providers, suppliers, pharmacies, and various healthcare services .

Posted 9/15/2026full-timeRemote • Arizona • United StatesJuniorMid-Level💰 $56,200 - $101,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical record reviews, coding accuracy, and fraud detection within behavioral health. Proficient in collaborating with stakeholders to ensure compliance with healthcare regulations and effective communication of audit findings.

Highest-signal resume keywords

Behavioral Health LicenseFraud, Waste, And Abuse ExperienceClinical Documentation SkillsMedical Record ReviewMicrosoft Office Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Record ReviewBehavioral Health Billing And CodingFraud DetectionCoding AnalysisClinical Documentation

Soft Skills

Strong CommunicationAttention To DetailOrganizational SkillsProblem-Solving SkillsTime Management

Tools & Technologies

Microsoft OfficeMS 365 Co-PilotExcelOutlookPowerPoint

Certifications & Qualifications

CPC CertificationLicensed Mental Health CounselorLicensed Clinical Social WorkerLicensed Marriage And Family TherapistLicensed Professional Counselor

Industry Keywords

Healthcare FraudBehavioral Health ComplianceManaged Care InvestigationsClinical Behavioral Health ExperienceService Authorization

About the role

Key responsibilities & impact

Conduct comprehensive reviews of medical records and documents supporting claims for providers, suppliers, pharmacies, and various healthcare services
Provide investigative support to the Special Investigations Unit related to coding and billing issues
Identify potential overpayments and suspected healthcare fraud and abuse
Verify service authorizations and written documentation against claim information
Ensure diagnosis and procedure codes supporting claims are appropriate and accurate
Coordinate medical necessity and level-of-care determinations with Medical Directors
Validate services against CMS and state-specific coverage, limitation, 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 medical-record reviews to identify fraud, waste, abuse, and inappropriate billing practices
Investigate and analyze provider billing patterns to determine payment based on records, claims, codes, regulations, guidelines, and policies
Prepare summaries of findings and recommend next steps for providers
Identify preventive measures and recommend policy, procedure, and/or provider-practice changes
Collaborate with investigators to identify abuse and fraud using clinical and coding expertise
Perform other duties as assigned
Comply with all policies and standards

Requirements

What you’ll need

Candidates must be fully licensed with one of the approved licenses upon submission of the Centene application
Master’s Degree required
2+ years of direct board clinical behavioral health experience with a fully independent clinical license
2+ years of fraud, waste, and abuse experience required
One required Behavioral Health license: LMHC, LCSW, LMFT, LPC, LMHP, or LIMHP
2+ years of experience in state agency investigations, special investigations in managed care, behavioral health provider reviews, medical record reviews, behavioral health billing/coding analysis, or behavioral health compliance preferred
3+ years of direct Psychotherapy or Inpatient group therapy experience in specified inpatient, residential, rehabilitation, military, or veteran healthcare settings preferred
Direct experience or working knowledge with FWA policies in state agency investigations or managed care investigations preferred
Strong clinical documentation and problem-solving skills
Openness, adaptability, and flexibility for business changes
Strong communication, attention to detail, organizational, and time management skills
Skilled in Microsoft Office applications, including MS 365 Co-Pilot, Excel, Outlook, Word, PowerPoint, OneNote, and Teams; openness to Generative AI tools preferred
Comfortable presenting findings concisely and effectively to various stakeholders
Working knowledge of behavioral health billing and coding basics preferred
CPC certification preferred but not required

Benefits

Comp & perks

Competitive pay
Health insurance
401K plan
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