Licensed Behavioral Health Investigator

Job Summary

To support the Special Investigations Unit, the full-time Licensed Behavioral Health Investigator will conduct comprehensive reviews of medical records and claims, identify potential fraud, waste, and abuse, and collaborate with internal and external resources to ensure compliance with coding and billing regulations in a remote environment.

Key responsibilities

• Perform retrospective and prepayment reviews of medical records to identify potential fraud, waste, and abuse
• Investigate and analyze provider billing patterns to determine payment accuracy based on medical records and regulatory guidelines
• Prepare summaries of findings and recommend preventative measures to improve internal policies and provider practices

Required qualifications

• Master's Degree with 2 years of relevant experience required
• 2+ years of clinical experience with an independent license (LMHC, LCSW, LMFT, LPC, LMHP, LIMHP) required
• At least 2 years of experience identifying or investigating fraud, waste, and abuse
• Experience in provider education and managed care organization preferred
• Coding certification preferred