Clinical Investigator (Behavioral Health)
Core
Conduct comprehensive reviews of medical records and documents to identify potential fraud, waste, and abuse in behavioral health care claims.
Role type
Senior IC clinical investigator (behavioral health)
Builds
Fraud detection reports and recommendations for internal policy changes
Domain
Healthcare + Behavioral Health + Fraud Investigation
Required skills
Behavioral health clinical license, retrospective and prepayment medical record review, coding and billing analysis, fraud pattern identification, regulatory guideline compliance, report writing
Preferred skills
Utilization management experience, auditing experience, provider education experience, managed care organization experience, coding certification
Technologies
CMS guidelines, State-specific coverage guidelines, medical record systems
Responsibilities
Perform retrospective and prepayment reviews of medical records to identify potential fraud, waste, and abuse; Investigate and analyze provider billing patterns to determine payment based on medical records and regulatory guidelines; Prepare summaries of findings and recommend next steps for providers; Identify preventative measures and recommend changes to internal policies and procedures; Collaborate with investigators to identify abuse and fraud by utilizing clinical and coding expertise
Seniority
Mid-level, hands-on IC
