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, focusing on identifying fraud, waste, and abuse in billing practices while working remotely nationwide.

Key responsibilities

• Perform retrospective and prepayment reviews of medical records to identify potential fraud and inappropriate billing practices
• 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 enhance internal policies and procedures

Required qualifications

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