Clinical Investigator, Behavioral Health

Centene Corporation

Clinical Investigator reviewing behavioral health claims and medical records for Centene, a national healthcare solutions provider. Identifying fraud, waste, abuse, overpayments, and billing irregularities for SIU investigations.

Posted 8/5/2026full-timeRemote • Arizona, New York, Texas, Wisconsin • 🇺🇸 United StatesJuniorMid-Level💰 $56,200 - $101,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in conducting comprehensive medical record reviews, identifying fraud, waste, and abuse, and providing investigative support in behavioral health settings. Proficient in clinical documentation, coding analysis, and effective communication of audit findings to stakeholders.

Highest-signal resume keywords

Master’s DegreeClinical License (LMHC, LCSW, LMFT, LPC, LMHP, LIMHP)Fraud, Waste, And Abuse ExperienceBehavioral Health Billing And Coding KnowledgeStrong Communication Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Record ReviewCoding AnalysisFraud InvestigationClinical DocumentationAudit ReportingService Authorization VerificationLevel-Of-Care DeterminationBehavioral Health CompliancePayment DeterminationPreventative Measures Identification

Soft Skills

Problem-SolvingAttention To DetailOrganizationTime ManagementAdaptability

Tools & Technologies

Microsoft OfficeExcelOutlookWordPowerPointOneNoteTeamsMS 365 Co-PilotGenerative AI Tools

Certifications & Qualifications

CPC Certification

Industry Keywords

Behavioral HealthHealth Care FraudCMS GuidelinesManaged-Care InvestigationsClinical Behavioral Health Experience

About the role

Key responsibilities & impact

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

Requirements

What you’ll need

Master’s Degree required
2+ years of direct board clinical behavioral health experience required
Fully independent clinical license required; one of LMHC, LCSW, LMFT, LPC, LMHP, or LIMHP
2+ years of fraud, waste, and abuse experience required
2+ years preferred in state agency investigations, managed-care special investigations, behavioral health provider reviews, medical-record reviews, behavioral health billing/coding analysis, or behavioral health compliance
3+ years preferred providing direct psychotherapy or inpatient group therapy in specified behavioral health facilities
Direct experience or working knowledge with FWA policies preferred
Strong clinical documentation and problem-solving skills required
Openness, adaptability, and flexibility for business changes
Strong communication, attention to detail, organization, and time-management skills required
Proficiency with Microsoft Office applications, including Excel, Outlook, Word, PowerPoint, OneNote, Teams, and MS 365 Co-Pilot preferred
Openness to using generative AI tools such as ChatGPT, Claude, or Gemini preferred
Ability to present findings concisely and effectively to various stakeholders required
Working knowledge of behavioral health billing and coding basics preferred
CPC certification preferred but not required

Benefits

Comp & perks

Competitive pay
Health insurance
401K
Stock purchase plans
Tuition reimbursement
Paid time off plus holidays
Flexible approach to work with remote, hybrid, field or office work schedules
Incentives may be included in total compensation
Accommodation support for applicants