Centene
Health Insurance
ClinicalInvestigator(SpecialInvestigationUnit)
“Clinical Investigator (Special Investigation Unit) at Centene. Skills: Clinical Investigation, Medical Record Auditing, Fraud and Abuse Detection. 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.. Perform retrospective and prepayment reviews of medical records to identify potential abuse and fraud and inappropriate billing practices”
What You'll Achieve.
Identify inappropriate billing practices; Recommend next steps; Identify potential abuse and fraud; Recommend payment based on medical records, claim history, billing codes, regulatory and state guidelines, and policies; Prevent future fraudulent and erroneous practices
Industry & Context.
Identify inappropriate billing practices; Identify potential abuse and fraud; Identify preventative measures
What They're Looking For.
Must Have
RN or LPN licensure, Coding experience, 2+ years related clinical experience in the field of obtained license required
Nice to Have
Associate's Degree related field or equivalent experience preferred, Provider education preferred
What You'll Do.
Audit medical records to identify inappropriate billing practices and recommend next steps through extensive review of claims data
and practice standards.
Perform retrospective and prepayment reviews of medical records to identify potential abuse and fraud and inappropriate billing practices
and identify provider billing patterns to recommend payment based on medical records
regulatory and state guidelines
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
Performs other duties as assigned.
Complies with all policies and standards.
How You'll Work.
Team & Collaboration
Consult investigators
Applying for this Clinical Investigator (Special Investigation Unit) role?
Most applicants get filtered before a human reads their resume. See if yours makes the cut.
How to Apply on Workday
- Workday has a multi-step form — save your progress after every section.
- "Apply With LinkedIn" can fail or lose data; manual entry is more reliable.
- Watch for the "Submit for Review" final step — hitting "Save" alone does not submit.
- Job requisition numbers are useful when following up with HR by email.
ANONYMOUS · UNFILTERED
What do employees actually say about Centene?
Real rants from real employees. Read before you apply.