Clinical Investigator

AmeriHealth Caritas - Harrisburg, PA3.4

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At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at

The Clinical Investigator is responsible for performing comprehensive clinical investigations and reporting for the purposes of identifying, investigating, and correcting fraudulent and/or abusive billing and coding practices. The Clinical Investigator reviews and analyzes medical records and other documentation to determine the accuracy and appropriateness of billing for documented services, including: assessing the appropriateness of services with respect to the Member's behavioral health condition; evaluating the accuracy of coding compared to medical records; and documenting rationale for review decisions. This position will manage a caseload from receipt of referral through case resolution resulting in preparation of all documentation for further investigation.

Major Accountabilities:
Provide clinical investigation analysis and reporting with specialized analytical skills and knowledge using internal and external data systems. Within areas of job responsibilities, identify systemic issues of fraud waste and/or abuse for the AmeriHealth Caritas Family of Companies.
Responsible for coordination with the Claims, Finance and other Departments regarding overpayments and case development.
Responsible for producing and developing case reporting as deliverables to designated LOB Oversights and others as deemed appropriate; and also updates case tracking system with all case actions and follow up. Responsible for making referrals to BPI, the OAG and others if deemed appropriate based on the development of a case.
Assist with coordination of recovery of overpayments related to fraudulent and/or abusive billing and coding practices; and education related to coding, medical record documentation requirements, and government- funded healthcare compliance and fraud, waste and abuse to Health Plan staff, vendors and contracted providers/facilities.
Participate in clinical Fraud, Waste and Abuse measurement projects, helping to develop enhanced clinical analysis data systems, and serving as a resource for developing Fraud, Waste and Abuse investigative results and solutions.
Interfaces with providers and may be responsible for conducting on-site audits.

Master’s Degree.
LCSW or LPC preferred.
CDC preferred.
Accredited Health Care Fraud Examiner (AHFI) and/or Certified Insurance Fraud Investigator (CIFI) Required or eligible to obtain within 1 year of employment.
Master’s degree in psychology, social work or related field and experience in providing direct service or involvement in Behavioral Health.
3-5 years of clinical treatment or service.
Experience with BH-MCOs preferred.
Knowledge of and experience working in various Behavioral Health levels of care.
Practical experience in the use of computerized databases.
Familiarity with claims payment, coding and reimbursement methodologies.
Ability to make decisions with supporting documentation independently, combined with team and leadership interactions
Ability to work collaboratively with the assigned line of business, County Oversight entities, providers, BPI, OMHSAS and others.Excellent verbal and written skills.
Strong research skills.