Position Purpose:
Conduct comprehensive reviews of medical records and documents supporting claims for providers, suppliers, and pharmacies to include but not limited to physicians, inpatient, outpatient, ancillary, behavioral health care, laboratory, etc. Provides investigative support to the Special Investigations Unit (SIU) related to coding and billing issues and identifies potential overpayments and suspected health care fraud and abuse. Position requires the associate to verify authorization for services and written documentation of services provided against claim information, ensure the appropriateness and accuracy of diagnosis and procedure codes supporting such claims, coordinate medical necessity and appropriate level of care determinations with Medical Directors, and validate services against CMS and State-specific coverage, limitations and exclusion guidelines. Coordinate with internal and external resources in determining the appropriateness of codes found in administrative, medical, claim and financial records, develop reports of findings and recommendations, communicate complex results of audit findings in meetings and/or judicial hearings, and assist SIU investigators during interviews, discussions and negotiations with providers, suppliers, and pharmacies.
Key Details : This is a remote position. Candidates must hold an active behavioral health license. Experience in utilization management, auditing, and coding is preferred.
Education/Experience:
Master’s Degree and 2 years of relevant experience required. 2+ years clinical experience with independent license required; 2 years of fraud, waste, and abuse experience required; experience in provider education and managed care organization preferred; coding certification preferred.
At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
...NORTH AMERICAN WAX COMPANY LLC in Bothell, WA is hiring a Guest Service Associate to be the first and last impression of guests, delivering a cheerful experience and promoting products and promotions. This is a sales-focused role in a busy skincare center. The position...
...ability to pursue that opportunity, and a voice in the decisions that affect their lives.JOIN OUR COMMUNITY ACTION TEAM: As a Weatherization Installer you will work onsite in residential buildings, both indoors and outdoors. Weatherization Installer work in the living...
...At Nox Group, we are dedicated to humanizing construction as one of the fastest-growing industrial enterprises in the US. Nox Group owns... ...and join our skilled team. We are seeking a Project Accountant to support some of the most innovative, complex, and large-scale...
...Job Description Job Description Set In Stone Construction is looking for an experienced Rough Carpenter to join our team. We are seeking a dependable, skilled carpenter with at least 10 years of hands-on construction experience who can work independently and produce...
...holidays and nights as needed (required) Must be able to successfully pass a background check and receive a license from the DE Lottery (required) 1 years: Previous money handling skills (required) Maintain knowledge of basic concepts and techniques (required)...