Clinical Investigator Behavioral Health
Core
Conduct comprehensive reviews of medical records and documents to identify potential fraud, waste, and abuse in behavioral health claims; provide investigative support to the Special Investigations Unit (SIU) regarding coding and billing issues.
Role type
Senior IC clinical investigator (behavioral health fraud & abuse)
Builds
Audit findings reports and recommendations for internal policy changes
Domain
Healthcare + Behavioral Health + Fraud Investigation
Deliverable
dashboards & analysis
Required skills
Medical record review, Behavioral health clinical expertise, Fraud/waste/abuse investigation, Coding and billing analysis, Regulatory guideline interpretation, Report writing
Preferred skills
State agency investigation experience, Psychotherapy/inpatient therapy experience, FWA policy knowledge, Generative AI tool usage
Technologies
MS 365 (Excel, Word, PowerPoint, Teams), ChatGPT, Claude, Gemini
Responsibilities
Perform retrospective and prepayment reviews of medical records to identify inappropriate billing practices; Investigate and analyze provider billing patterns to determine payment accuracy; Prepare summaries of findings and recommend next steps for providers; Identify preventative measures to reduce future fraudulent practices; Collaborate with investigators to identify abuse using clinical and coding expertise; Communicate complex audit findings in meetings and judicial hearings.
Seniority
Senior, hands-on IC
