Clinical Investigator I (Special Investigation Unit)

Overview

• You could be the one who changes everything for our 28 million members.
• Centene is transforming the health of our communities, one person at a time.
• As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.
• Remote nationwide position
• Ideal candidate is an RN or LPN with coding experience
• Preferred experience in an insurance company, SIU, or fraud department
• Strong fit: experience reviewing medical records for fraud investigations
• Physician office experience preferred, especially in a specialist practice
• Background in record review and documentation quality is highly valued
• Documentation Improvement Specialist experience is also a strong match

Position Purpose

• 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.
• 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
• Performs other duties as assigned.
• Complies with all policies and standards.

Education/Experience

Licenses/Certifications

Benefits