Centene Management Company LLC is hiring a Clinical Investigator I for its Special Investigation Unit. You will audit medical records to identify inappropriate billing practices and recommend next steps through extensive review of claims data, medical records, corporate policy, and state/federal guidelines, supporting our mission of transforming community health.
What You'll Do
- Perform retrospective and prepayment reviews of medical records to identify potential abuse, fraud, and inappropriate billing.
- Investigate, analyze, and identify provider billing patterns to recommend payment based on records, claim history, codes, and regulatory guidelines.
- Prepare summaries of findings and recommend next steps for providers.
- Identify preventative measures and recommend changes to internal policies or provider practices.
- Consult with investigators to identify abuse and fraud by utilizing clinical and coding expertise to analyze billing patterns.
- Perform other duties as assigned and comply with all policies and standards.
What We're Looking For
- 2+ years of related clinical experience in the field of the obtained license.
- Coding certification from an accredited organization (AAPC or AHIMA), or an RN, LPC, LPN, LCSW, LMHC, PT, OT, ST, or related license.
Nice to Have
- Associate's Degree in a related field or equivalent experience.
- Provider education experience.
- CPC or CPMA Certification.
Benefits & Compensation
- Compensation range: $56,200.00 - $101,000.00 per year.
- Health insurance.
- 401K and stock purchase plans.
- Tuition reimbursement.
- Paid time off plus holidays.
Work Mode
This position offers a flexible approach to work with remote schedules.
We are an equal opportunity employer.
