Investigator

• 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

Explore Clinical Investigator, Behavioral Health at Centene Corporation. Review requirements and application details.