Clinical Investigator Behavioral Health

Centene
Texas, Georgia, Nebraska, Wisconsin, Arizona, Ohio, Michigan, Florida, Washington, North Carolina, Nevada, Maryland, Pennsylvania, Iowa, Colorado, Missouri, Kentucky, Oklahoma
Workplace: RemoteFull timeUSD 56,200 - 101,000 annuallyFunction: Administration & Executive AssistanceExperience: 2+ yearsEducation: mastersSkills: ["Communication","Problem-solving","Attention to detail","Organizational skills","Time management"]

Conduct retrospective and prepayment reviews of medical records and claim documentation to identify fraud, waste, and abuse in behavioral health services. Verify authorization, validate diagnosis and procedure coding, assess medical necessity and coverage guidance, and coordinate with Medical Directors and SIU teams. Analyze billing patterns, prepare findings and recommendations, present results to stakeholders and support investigator interviews to help drive next steps and policy/provider improvements.

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Centene
Centene
2 days ago

Clinical Investigator Behavioral Health

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Last checked: 2 hours agoStatus: Live

Job Summary

Conduct retrospective and prepayment reviews of medical records and claim documentation to identify fraud, waste, and abuse in behavioral health services. Verify authorization, validate diagnosis and procedure coding, assess medical necessity and coverage guidance, and coordinate with Medical Directors and SIU teams. Analyze billing patterns, prepare findings and recommendations, present results to stakeholders and support investigator interviews to help drive next steps and policy/provider improvements.
Location: Texas, Georgia, Nebraska, Wisconsin, Arizona, Ohio, Michigan, Florida, Washington, North Carolina, Nevada, Maryland, Pennsylvania, Iowa, Colorado, Missouri, Kentucky, Oklahoma
Workplace: Remote
Employment Type: Full time
Job Function: Administration & Executive Assistance
Seniority: Mid level

Key Responsibilities

  • •Conduct comprehensive reviews of medical records and supporting documentation for providers, suppliers, and pharmacies to validate authorization and coding accuracy.
  • •Perform retrospective and prepayment reviews to identify potential fraud, waste, abuse, and inappropriate billing practices.
  • •Investigate and analyze provider billing patterns to determine payment based on clinical records, claim history, codes, and regulatory/state guidelines.
  • •Coordinate with Medical Directors on medical necessity and appropriate level of care determinations, validating services against CMS and state coverage guidance.
  • •Prepare findings and recommendations, communicate results to stakeholders in meetings or judicial hearings, and assist SIU investigators during provider/supplier/pharmacy interviews and discussions.

Pay and Benefits

Salary: USD 56,200 - 101,000 annually
Perks:Health Insurance401kEquityPaid LeaveRemote Work

Key Requirements

  • •Master’s Degree and 2+ years of direct board clinical behavioral health experience with a fully independent clinical license.
  • •2+ years of fraud, waste, and abuse experience.
  • •One of the required Behavioral Health licenses: LMHC, LCSW, LMFT, LPC, LMHP, or LIMHP.
  • •2+ years of experience in state agency investigations, special investigations in managed care, or behavioral health provider reviews.
  • •Strong clinical documentation, problem-solving, and attention to detail to support coding and medical record review accuracy.
Experience:2+ yearsBehavioral healthFraud waste abuseManaged careState agency investigations
Education:Master's
Skills:CommunicationProblem-solvingAttention to detailOrganizational skillsTime management
Licenses:LMHCLCSWLMFTLPCLMHPLIMHP
Certifications:Certified Professional Coder (CPC)
Tech Stack:Microsoft OfficeMS 365 Co-PilotExcelOutlookWordPowerPointOneNoteTeamsChatGPTClaudeGemini

Company Brief

Centene
Centene Corporation is a diversified, multinational healthcare enterprise that provides government-sponsored and commercial healthcare programs and services, specializing in Medicaid, Medicare, and specialty benefits management across the United States.
Industry: Health Insurance (Payers)
Company Size: Enterprise (1,001+ employees)
Revenue: USD 1B+
Growth: Public Company
Valuation: Public Company (Market Cap in USD)
Funding: IPO / Publicly Listed
Headquarters: St. Louis, United States
Founded: 1984
WebsiteLinkedIn