records and documents supporting claims for providers, suppliers, and pharmacies to include but not limited to physicians, inpatient, outpatient, ancillary, behavioral health care, laboratory, etc. Provides investigative support to the Special Investigations Unit (SIU) related to coding and billing issues and identifies potential overpayments and suspected health care fraud and abuse.
Position requires the associate to verify authorization for services and written documentation of services provided against claim information, ensure the appropriateness and accuracy of diagnosis and procedure codes supporting such claims, coordinate medical necessity and appropriate level of care determinations
with Medical Directors, and validate services against CMS and State-specific coverage, limitations and exclusion guidelines. Coordinate with internal and external resources in determining the appropriateness of codes found in administrative, medical, claim and financial records, develop reports of findings and recommendations, communicate complex results of audit findings in meetings and/or judicial hearings, and assist SIU investigators during interviews, discussions and negotiations with providers, suppliers, and pharmacies.
Perform retrospective and prepayment reviews of medical records to identify potential fraud, waste, and abuse and inappropriate billing practices. Investigate,
analyze, and identify provider billing patterns to determine 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. Collaborate with investigators to identify abuse and fraud by utilizing clinical and coding expertise to analyze patterns in billing activities. Education/Experience: Master s Degree and 2 years of relevant experience required. 2+ years clinical experience with independent license required; 2 years of fraud, waste, and abuse experience required; experience in provider education and managed care organization preferred; coding certification preferred.
License/Certification: Behavioral health license - LMHC, LCSW, LMFT, LPC, LMHP, LIMHPOur Comprehensive Benefits Package: Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.
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, interaction, interactionual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Associated topics: adult, behavioral, behavioral healthcare, clinical, clinician, field, mental, msw, outpatient, youth
tuition reimbursement, annual uniform allowance, holiday pay etc. Days: Thursday, Friday, and Saturday Hours: 7:00 p. m. to 7:00 a. m. (NIGHTS) Position: To provide compatibility testing and consultation services for resolution of complex serological problems.
Qualifications: Bachelor of Science degree with completion of a Medical Technology (MT)/Medical Laboratory Science (MLS) training program ASCP registration preferred Ability to resolve complex serological problems independently Provide clear and concise consultation to other medical technologists and physicians Excellent oral and written communication skills Team player Special Physical Requirements: Must have full sight Hearing
impairment requiring a hearing aid(s) is acceptable Must be fully ambulatory Moderate lifting required Special Licensing/Certifications: Completion of accredited Medical Technology/Medical Laboratory Science training program Primary Responsibilities: Perform quality control, calibration, maintenance and verification procedures for laboratory equipment Receive hospital orders Work with lab couriers or Storage and Distribution on the coordination of specimen pick-ups and product delivery Review patients medical and transfusion history and correlate with laboratory investigation Perform ABO, Rh, antibody detection and compatibility testing procedures for transfusion service clients Perform antibody
identification for transfusion service clients and member hospital clients Fill orders for antigen negative requests Perform RBC crossmatch and procedures selecting antigen negative units as needed Perform antibody titration procedures Perform complex antibody identification procedures using different testing platforms and reagents Prepare consultation reports Takes call as needed for laboratory coverage Clean and maintain work areas Click the link below to learn fun facts about working for Our Blood Institute!
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