Behavioral Health Investigator & Coding Auditor (Remote)

Centene Corporation

Michigan

Hybrid

USD 56,000 - 101,000

Full time

8 days ago

Application generator

An application made for this job — a tailored resume and cover letter that speak straight to the posting.

Get past ATS filters

Job summary

Centene Corporation seeks a licensed behavioral health auditor to conduct retrospective reviews of medical records supporting claims for providers, suppliers and pharmacies. You will verify authorization and coding accuracy, support SIU investigations, and help determine medical necessity and level of care.

The role requires a Master’s in behavioral health, an independent license and 2+ years in fraud/waste/abuse.

Qualifications

Master’s degree in behavioral health and 2+ years with an independent clinical license.
2+ years of fraud, waste and abuse experience; CPC preferred but not required.
Licensed in LMHC/LCSW/LMFT/LPC/LMHP/LIMHP or equivalent.

Responsibilities

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 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.
Communicate complex results of audit findings in meetings and/or judicial hearings; assist SIU investigations during interviews and negotiations.