Clinical Investigator – Behavioral Health

About the role

Centene is seeking a Clinical Investigator specialized in Behavioral Health to support its Special Investigations Unit. The role involves reviewing medical records, verifying claim accuracy, and identifying potential fraud, waste, and abuse across a range of provider types.

Key responsibilities

• Conduct comprehensive retrospective and pre‑payment reviews of behavioral health medical records and related claims.
• Validate authorization, diagnosis, and procedure codes against CMS and state guidelines.
• Collaborate with Medical Directors and internal teams to determine medical necessity and appropriate level of care.
• Develop detailed audit reports, present findings in meetings or hearings, and assist investigators during provider interviews.
• Identify billing patterns, recommend preventative measures, and suggest policy or practice changes to reduce fraud.

Required profile

• Master’s degree and a fully independent clinical license in behavioral health.
• Minimum 2 years of direct clinical experience and 2 years of fraud, waste, and abuse investigation experience.
• Preferred Certified Professional Coder (CPC) certification.

Required skills

• Medical coding expertise, particularly for behavioral health services.
• Strong knowledge of CMS and state-specific coverage, limitation, and exclusion guidelines.