Remote Behavioral Health Investigator & Coding Auditor

Centene Corporation; Missouri; Hybrid; USD 56,000 - 101,000; Full time

Job summary

Centene Corporation is seeking a qualified professional for a remote Investigative Auditor role focused on reviews of medical records to support claims and detect fraud, waste, and abuse in the healthcare system. Requires a behavioral health license and experience in utilization management, auditing, and coding.

The role emphasizes verification of medical necessity, coding accuracy, and alignment with CMS and state guidelines, with collaborative work across SIU and providers.

Qualifications

• 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.
• Coding certification preferred.

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 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.
• 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 and standards.

Skills

Utilization management

Auditing

Medical coding

Clinical experience

Education

Master's Degree

2+ years relevant experience

Job description

Centene Corporation is seeking a qualified professional for a remote Investigative Auditor role focused on reviews of medical records to support claims and detect fraud, waste, and abuse in the healthcare system. Requires a behavioral health license and experience in utilization management, auditing, and coding.

The role emphasizes verification of medical necessity, coding accuracy, and alignment with CMS and state guidelines, with collaborative work across SIU and providers.