Clinical Investigator – Behavioral Health

Centene Corporation

Clinical Investigator reviewing behavioral health claims and medical records for Centene. Supporting SIU healthcare fraud, waste, abuse, coding, and billing investigations remotely.

Posted 9/8/2026full-timeRemote • Montana, North Carolina • 🇺🇸 United StatesJuniorMid-Level💰 $56,200 - $101,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in conducting comprehensive medical record reviews, analyzing billing patterns, and ensuring compliance with CMS and state-specific guidelines. Proficient in identifying healthcare fraud, waste, and abuse while effectively communicating complex findings to stakeholders.

Highest-signal resume keywords

Master’s DegreeClinical ExperienceFraud, Waste, And Abuse ExperienceBehavioral Health LicenseCoding Certification

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Medical Record ReviewClaims ReviewCoding And Billing KnowledgeMedical Necessity DeterminationLevel-Of-Care DeterminationBilling Pattern AnalysisRegulatory ComplianceAudit Findings CommunicationProvider EducationReport Development

Soft Skills

Analytical SkillsCommunication SkillsCollaboration Skills

Certifications & Qualifications

Behavioral Health LicenseCoding Certification

Industry Keywords

Healthcare FraudWaste And AbuseCMS GuidelinesState-Specific Coverage GuidelinesManaged Care Organization

About the role

Key responsibilities & impact

Conduct comprehensive reviews of medical records and documents supporting provider, supplier, pharmacy, and behavioral health claims
Provide investigative support to the Special Investigations Unit on coding and billing issues
Identify potential overpayments and suspected healthcare fraud, waste, and abuse
Verify service authorizations and documentation against claim information
Ensure the appropriateness and accuracy of diagnosis and procedure codes
Coordinate medical necessity and level-of-care determinations with Medical Directors
Validate services against CMS and state-specific coverage, limitations, and exclusion guidelines
Coordinate with internal and external resources to determine code appropriateness in administrative, medical, claim, and financial records
Develop reports of findings and recommendations
Communicate complex audit results in meetings and/or judicial hearings
Assist SIU investigators during provider, supplier, and pharmacy interviews, discussions, and negotiations
Perform retrospective and prepayment medical-record reviews
Investigate and analyze provider billing patterns to determine payment
Prepare findings summaries and recommend next steps for providers
Identify preventive measures and recommend policy, procedure, and provider-practice changes
Collaborate with investigators to identify abuse and fraud using clinical and coding expertise
Perform other duties as assigned
Comply with all policies and standards

Requirements

What you’ll need

Master’s Degree required
2 years of relevant experience required
2+ years clinical experience with independent license required
2 years of fraud, waste, and abuse experience required
Behavioral health license required: LMHC, LCSW, LMFT, LPC, LMHP, or LIMHP
Experience in provider education and managed care organization preferred
Coding certification preferred
Ability to conduct comprehensive medical-record and claims reviews
Knowledge of coding and billing issues, medical necessity, level-of-care determinations, CMS and state-specific coverage guidelines
Ability to analyze billing patterns, claim history, billing codes, regulatory and state guidelines, and policies
Ability to communicate complex audit findings in meetings and/or judicial hearings
Applicants must be able to work remotely from anywhere within the United States
Availability to work Monday through Friday

Benefits

Comp & perks

Competitive pay
Health insurance
401K plan
Stock purchase plans
Tuition reimbursement
Paid time off plus holidays
Flexible approach to work with remote, hybrid, field or office work schedules
Equal opportunity employer committed to diversity