临床研究者 I（特别调查小组）
Clinical Investigator I (Special Investigation Unit)
职位职责：
审核医疗记录，以识别不当的收费行为，并通过全面审查索赔数据、医疗记录、公司政策、州/联邦政策和行业标准，提出下一步建议。
关键要求：优先考虑具备编码认证、护士编码经验及CPT编码经验的候选人。
- 对医疗记录进行回顾性及预付款审查，以识别潜在的滥用和欺诈行为及不当收费行为
- 调查、分析并识别提供者的收费模式，根据医疗记录、索赔历史、收费代码、监管和州指南及政策，提出支付建议
- 汇总发现结果，并为提供者推荐下一步措施
- 识别预防措施，并建议对内部政策和程序以及/或提供者实践进行更改，以防止未来的欺诈和错误行为
- 与调查人员合作，利用临床和编码专业知识分析收费活动中的模式，以识别滥用和欺诈行为
- 执行其他指派的任务
- 遵守所有政策和标准
教育/经验：相关领域的专科文凭或同等经验优先
需具备2年以上相关临床经验
提供者教育背景优先
资格证书：
来自认可机构的编码认证（美国专业编码师协会或美国健康信息管理协会）、注册护士（RN）、心理咨询师（LPC）、助理护士（LPN）、临床社会工作者（LCSW）、心理健康咨询师（LMHC）、物理治疗师（PT）、职业治疗师（OT）或理疗师（ST）或其他相关执照。必需
在Centene，我们帮助人们获得他们需要的医疗服务，以过上更健康的生活——你在这里的工作每天都能真正产生影响。你将面对有意义的挑战，直接支持个人、家庭和社区，在提升技能的同时让医疗更加可及和高效。这是一份你能看到成果的工作，由一支致力于在工作时间之外改善生活的团队所支持。
Centene提供全面的福利计划，包括具有竞争力的薪酬、健康保险、401K和股票购买计划、学费报销、带薪休假及节假日，以及灵活的工作方式，支持远程、混合、现场或办公室工作安排。实际薪酬将根据个人技能、经验、教育和其他法律允许的与工作相关的因素（包括全职或兼职状态）进行调整。总薪酬可能还包括其他形式。
查看英文原文
Position Purpose:
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.
Key Details: Preferred qualifications include coding certification, nurse coding experience, and experience with CPT coding.
- Perform retrospective and prepayment reviews of medical records to identify potential abuse and fraud and inappropriate billing practices
- Investigate, analyze, and identify provider billing patterns to recommend payment based on medical records, claim history, billing codes, regulatory and state guidelines, and policies
- 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.
Education/Experience: Associate's Degree related field or equivalent experience preferred
2+ years related clinical experience in the field of obtained license required
Provider education preferred
Licenses/Certifications:
Coding certification from an accredited organization (American Academy of Professional Coders or American Health Information Management Association), RN, LPC, LPN, LCSW, LMHC, PT, OT, or ST or related license. required
At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
Originally posted on Himalayas