Centene is looking for a Clinical Investigator I for our Special Investigation Unit. In this role, you will audit medical records to identify inappropriate billing practices and recommend next steps through extensive review of claims data, medical records, corporate policy, state/federal policy, and practice standards. You'll be part of our mission of transforming the health of our communities, one person at a time.

What You'll Do

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.
Perform other duties as assigned.
Comply with all policies and standards.

What We're Looking For

2+ years of related clinical experience in the field of your obtained license.
Coding certification from an accredited organization (American Academy of Professional Coders or American Health Information Management Association), RN, LPC, LPN, LCSW, LMHC, PT, OT, or ST or related license.