Jobs for Humanity is partnering with Centene to build an inclusive and just employment ecosystem. Therefore, we prioritize individuals coming from the following communities: Refugee, Neurodivergent, Single Parent, Blind or Low Vision, Deaf or Hard of Hearing, Black, Hispanic, Asian, Military Veterans, the Elderly, the LGBTQ, and Justice Impacted individuals. This position is open to candidates who reside in and have the legal right to work in the country where the job is located.

Company Name: Centene

🔘 **Position Title**: Medical Records Review Specialist - Join us in transforming healthcare for 28 million members! 🔘 **Position Purpose**: Conduct comprehensive reviews of medical records and support claims for healthcare providers. Collaborate with the Special Investigations Unit (SIU) to identify potential overpayments, health care fraud, and abuse. Verify authorization, diagnose accuracy, and coordinate care with Medical Directors. Validate services against coverage guidelines and assist SIU in interviews and negotiations. Responsibilities: - Perform retrospective and prepayment reviews of medical records to identify potential fraud, waste, and abuse. - Investigate and analyze provider billing patterns for accurate payment determination. - Prepare summaries and recommend actions for providers. - Identify preventative measures and recommend policy changes to prevent future fraudulent practices. - Collaborate with investigators to identify abuse and fraud through coding and clinical expertise. 🔘 **Education/Experience**: Master's Degree and 2 years of relevant experience required. 2+ years of clinical experience with independent license and fraud, waste, and abuse experience. Preferred experience in provider education and managed care organization. Coding certification preferred. 🔘 **License/Certification**: Behavioral health license (LMHC, LCSW, LMFT, LPC, LMHP, LIMHP) required. 🔘 **Benefits Package**: We prioritize your well-being! - Flexible work options: remote work, hybrid schedules, and dress flexibility. - Competitive pay and paid time off, including holidays. - Health insurance coverage for you and your dependents. - 401(k) and stock purchase plans. - Tuition reimbursement and top-notch training and development opportunities. 🔘 **Equal Opportunity Employer**: Centene promotes diversity and values our unique differences. All qualified individuals, regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other protected characteristic are encouraged to apply. We look forward to receiving your application and having you join our team in making a positive impact on communities' health! Please note that the formatting may not be accurately represented in the plain text response.