Clinical Investigator
Core
Detects and audits aberrant billing patterns within claims and clinical documentation using forensic clinical expertise to protect healthcare spend integrity.
Role type
Senior clinical investigator (forensic medical audit)
Builds
Evidentiary files for potential recovery, legal action, or referrals to outside agencies
Domain
Health insurance / Forensic clinical auditing
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Forensic clinical expertise, Medical record review, Clinical guideline application (CMS, MCG), Billing code validation (CPC, HCPCS, ICD-10), Provider behavior analysis, Audit reporting, Education delivery to providers
Preferred skills
Case management, Claims processing, HIPAA compliance, Trend identification (cloned documentation), Non-confrontational feedback delivery
Technologies
CMS, MCG, CPC, HCPCS, ICD-10
Responsibilities
Conduct clinical audits into suspected FWA with high autonomy, Document findings including formal reports and audit logs, Develop and present FWA-related education for teams, Partner with investigators to build evidentiary files
Seniority
Senior, hands-on IC