Medical Billing Integrity Investigator

Centene Corporation; Missouri; Hybrid; USD 65,000 - 85,000; Full time

Benefits offered by this job

Flexible schedules

Remote/hybrid/office options

Job summary

Centene Corporation is seeking an Auditor to review medical records and claims data in Missouri, identifying inappropriate billing practices and advising on corrective actions. The role focuses on retrospective and prepayment reviews, analyzing provider patterns and regulatory guidelines to ensure compliant payment determinations.

The position requires a coding certification and related clinical experience, with preferred credentials in CPT coding.

Qualifications

• Associate's Degree related field or equivalent experience preferred
• 2+ years related clinical experience in the field of obtained license required
• Provider education preferred

Responsibilities

• Perform retrospective and prepayment reviews of medical records to identify potential abuse and fraud and inappropriate billing practices
• Investigate, analyze, and identify provider billing patterns to recommend 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 and/or provider practices to prevent future fraudulent and erroneous practices
• Consult 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 and standards.

Skills

Coding certification

Nurse coding

CPT coding

Education

Associates degree or equivalent experience

2+ years clinical experience

Job description

Centene Corporation is seeking an Auditor to review medical records and claims data in Missouri, identifying inappropriate billing practices and advising on corrective actions. The role focuses on retrospective and prepayment reviews, analyzing provider patterns and regulatory guidelines to ensure compliant payment determinations.

The position requires a coding certification and related clinical experience, with preferred credentials in CPT coding.