Clinical Investigator (Behavioral Health)

Location: Remote-MO

Salary: $56,200–$101,000 per year

Company

A healthcare organization focused on connecting people with accessible, effective care and improving health outcomes.

What you will do

• Conduct retrospective and prepayment reviews of medical records, claims, authorization documents, and billing information.
• Investigate provider billing patterns to identify potential fraud, waste, abuse, overpayments, and inappropriate billing practices.
• Validate diagnosis and procedure codes, medical necessity, levels of care, and services against CMS, state, and organizational guidelines.
• Prepare findings reports, recommend corrective and preventive actions, and advise on changes to provider practices and internal policies.
• Collaborate with Special Investigations Unit investigators, Medical Directors, and internal and external resources.
• Communicate complex audit findings in meetings or judicial hearings and support provider interviews, discussions, and negotiations.

Requirements

• Active behavioral health license required: LMHC, LCSW, LMFT, LPC, LMHP, or LIMHP.
• Master’s degree and at least 2 years of relevant experience.
• At least 2 years of clinical experience with an independent license.
• At least 2 years of experience in fraud, waste, and abuse.
• Experience in utilization management, auditing, and coding is preferred.
• Provider education or managed care experience is preferred; coding certification is also preferred.

Culture & Benefits

• Remote work arrangement with flexible remote, hybrid, field, or office schedules available across the organization.
• Health insurance, 401(k), and stock purchase plans.
• Tuition reimbursement, paid time off, and holidays.
• Work focused on supporting individuals, families, and communities through improved healthcare access.