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Clinical Investigator
Location
United States
Posted
33 days ago
Salary
$72.0K - $94.5K / year
Seniority
Mid Level
No structured requirement data.
Job Description
Role Description
The Senior Analyst, SIU Clinical Investigator detects and audits aberrant billing patterns within claims and clinical documentation, using forensic clinical expertise to protect the integrity of healthcare spend. You will:
- Perform comprehensive pre-payment and post-payment reviews of medical records to ensure billed services align with established clinical guidelines, CMS regulations, and contractual obligations.
- Analyze provider behavior to identify schemes such as record cloning, upcoding, and unbundling that may be invisible to automated systems.
- Act as a clinical subject matter expert to translate audit findings into relevant education.
- Facilitate professional discussions with colleagues and providers to correct billing behaviors and promote long-term compliance.
- Partner with clinical and non-clinical investigators to build evidentiary files for potential recovery, legal action, or referrals to appropriate outside agencies.
You will report into the Investigations Manager, SIU.
Qualifications
- Active, unrestricted Registered Nurse (RN) license.
- 3+ years of direct patient care clinical experience. Case Management experience a bonus.
- 2+ years of experience in Medical Review, Utilization Management, or Clinical Documentation Improvement, featuring demonstrated expertise in the forensic application of complex clinical guidelines (e.g., MCG, CMS, and specialty-specific professional organizations) to multifaceted medical records.
- Experience conducting forensic medical audit with a focus on validating that clinical narrative supports the specificity and necessity of billed CPC, HCPCS, and ICD-10 codes.
Requirements
- Bachelor of Science in Nursing (BSN), Associate Degree in Nursing (ADN) with a Bachelor of Science in Health Administration, Clinical Informatics, or a related Medical Science field, or Associate Degree in Nursing (ADN) with 5+ years of specialized clinical audit experience.
- Experience working in health insurance with competency regarding claims processing, billing, reimbursement, or provider contracting.
- Experience delivering feedback or education to providers/physicians in a professional, non-confrontational, and persuasive manner.
- Identifying trends, for example “cloned documentation” or change in billing habits of a provider.
- Experience with HIPAA, data privacy, and/or data security processes.
- Certified Case Manager (CCM), Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or similar.
Benefits
- Employee benefits including medical, dental, and vision benefits.
- 11 paid holidays.
- Paid sick time.
- Paid parental leave.
- 401(k) plan participation.
- Life and disability insurance.
- Paid wellness time and reimbursements.
- Participation in Oscar's unlimited vacation program.
- Annual performance bonuses.
Job Requirements
- Active, unrestricted Registered Nurse (RN) license.
- 3+ years of direct patient care clinical experience. Case Management experience a bonus.
- 2+ years of experience in Medical Review, Utilization Management, or Clinical Documentation Improvement, featuring demonstrated expertise in the forensic application of complex clinical guidelines (e.g., MCG, CMS, and specialty-specific professional organizations) to multifaceted medical records.
- Experience conducting forensic medical audit with a focus on validating that clinical narrative supports the specificity and necessity of billed CPC, HCPCS, and ICD-10 codes.
- Bachelor of Science in Nursing (BSN), Associate Degree in Nursing (ADN) with a Bachelor of Science in Health Administration, Clinical Informatics, or a related Medical Science field, or Associate Degree in Nursing (ADN) with 5+ years of specialized clinical audit experience.
- Experience working in health insurance with competency regarding claims processing, billing, reimbursement, or provider contracting.
- Experience delivering feedback or education to providers/physicians in a professional, non-confrontational, and persuasive manner.
- Identifying trends, for example “cloned documentation” or change in billing habits of a provider.
- Experience with HIPAA, data privacy, and/or data security processes.
- Certified Case Manager (CCM), Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or similar.
Benefits
- Employee benefits including medical, dental, and vision benefits.
- 11 paid holidays.
- Paid sick time.
- Paid parental leave.
- 401(k) plan participation.
- Life and disability insurance.
- Paid wellness time and reimbursements.
- Participation in Oscar's unlimited vacation program.
- Annual performance bonuses.
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