Licensed Clinical Investigator
Job Summary
To support the Special Investigations Unit, the full-time Licensed Clinical Investigator will conduct comprehensive reviews of medical records and claims related to behavioral health, identifying potential fraud and ensuring compliance with coding and billing regulations in a remote setting.
Key responsibilities
- Perform retrospective and prepayment reviews of medical records to identify potential fraud, waste, and abuse
- Investigate provider billing patterns to determine payment accuracy based on medical records and regulatory guidelines
- Prepare findings and recommend changes to prevent future fraudulent practices
Required qualifications
- Master's Degree and 2+ years of direct clinical behavioral health experience with a fully independent clinical license
- 2+ years of experience in fraud, waste, and abuse investigations
- Behavioral health license required (LMHC, LCSW, LMFT, LPC, LMHP, or LIMHP)
- Strong clinical documentation and problem-solving skills
- Experience with behavioral health billing and coding basics preferred
Complete Job Description
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