Remote Behavioral Health Investigator & Coding Auditor

Centene Corp.; United States; Remote; USD 56,000 - 101,000; Full time

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Remote work flexibility

Job summary

Centene Corp. seeks a seasoned claims auditor to conduct comprehensive retrospective and prepayment reviews of medical records supporting claims from providers, suppliers and pharmacies, ensuring accurate coding and medical necessity.

This remote role requires an active behavioral health license and experience in utilization management, auditing and fraud, waste and abuse investigations, with collaboration across SIU teams and Medical Directors to identify overpayments and improve controls.

Qualifications

• Master’s Degree in a relevant field.
• 2+ years clinical experience with independent license required; fraud, waste and abuse experience preferred.
• Coding certification preferred.

Responsibilities

• Perform retrospective and prepayment reviews of medical records to identify fraud, waste, and abuse.
• Investigate provider billing patterns to determine payment based on medical records and codes.
• Prepare summaries of findings and recommend next steps for providers.
• Identify preventative measures and propose changes to internal policies and procedures.
• Collaborate with investigators to identify abuse and fraud using clinical and coding expertise.
• Complies with all policies and standards.

Skills

Utilization management

Auditing

Coding

Education

Master’s Degree in a relevant field

Job description

Centene Corp. seeks a seasoned claims auditor to conduct comprehensive retrospective and prepayment reviews of medical records supporting claims from providers, suppliers and pharmacies, ensuring accurate coding and medical necessity.

This remote role requires an active behavioral health license and experience in utilization management, auditing and fraud, waste and abuse investigations, with collaboration across SIU teams and Medical Directors to identify overpayments and improve controls.