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Clinical Reviewer I (Special Investigation Unit)

Company: Centene
Location: Chesterfield
Posted on: December 4, 2019

Job Description:

Clinical Reviewer I (Special Investigation Unit) - RN, LPC Position Purpose: Perform retrospective and prepayment reviews of medical records to identify potential abuse and fraud and inappropriate billing practices Investigate, analyze, and identify provider billing patterns to recommend payment based on medical records, claim history, billing codes, regulatory and state guidelines, and policies Prepare summary of findings and recommend next steps for providers Identify preventative measures and recommend changes to internal policies and procedures and/or provider practices to prevent future fraudulent and erroneous practices Consult investigators to identify abuse and fraud by utilizing clinical and coding expertise to analyze patterns in billing activities Audit medical records to identify inappropriate billing practices and recommend next steps through extensive review of claims data, medical records, corporate policy, state/federal policy, and practice standards. Experience/Experience: Associate's degree in a related field or equivalent experience. Coding Certification and 2+ years of medical coding experience; or RN, LPC, LCSW, LMHC, PT, OT or ST license and 2+ years of related clinical experience in the field of obtained license. Experience in provider education preferred. Licenses/Certifications: Coding certification from an accredited organization (American Academy of Professional Coders or American Health Information Management Association), RN, LPC, LCSW, LMHC, PT, OT, or ST license. Preferred Licensure: RN and LPC. 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. Quality Assurance USA-Missouri-Chesterfield USA-North Carolina-Charlotte Corporate Full-time

Keywords: Centene, Chesterfield , Clinical Reviewer I (Special Investigation Unit), Healthcare , Chesterfield, Missouri

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