Clinical Investigator II
Core
Clinical subject matter expert leading complex healthcare fraud, waste, and abuse investigations, medical audits, and provider interviews to safeguard plan assets and ensure quality member care.
Role type
Senior IC clinical investigator (healthcare fraud)
Builds
Investigative reports, corrective action plans, and regulatory submissions for healthcare payers
Domain
Healthcare compliance and fraud detection
Required skills
Clinical judgment, medical necessity evaluation, data mining, analytical skills, report writing, regulatory liaison, interview techniques, coding knowledge (CPT, ICD-10-CM, HCPCS), Microsoft Office proficiency
Preferred skills
Managed care experience, Medicaid fraud detection, behavioral health clinical experience, claims processing experience, healthcare coding certification
Technologies
Case Shield, anti-fraud platforms, Microsoft Excel
Responsibilities
Lead clinically complex FWA investigations including medical record audits and provider interviews; Prepare investigative reports with findings and corrective action recommendations; Partner with internal departments to implement corrective actions; Serve as clinical resource for medical necessity and coverage policy questions; Triage referrals using clinical judgment and data analytics; Conduct data mining to identify FWA and refine detection algorithms; Support law enforcement investigations and regulatory reporting
Seniority
Senior, hands-on IC
