Clinical Fraud Investigator II
Core
Investigate potential fraud and abuse in healthcare claims by analyzing clinical data, medical records, and billing guidelines to identify risks and recommend loss control interventions.
Role type
Senior IC clinical fraud investigator
Builds
Fraud prevention controls and risk avoidance strategies for healthcare payers
Domain
Healthcare / Insurance / Compliance
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical evaluation, retrospective claims analysis, medical record review, fraud detection, compliance analysis, data analysis, investigation, risk assessment, intervention recommendation, healthcare billing guidelines knowledge
Preferred skills
Advanced Excel (Pivot Tables)
Technologies
Excel
Responsibilities
Perform comprehensive analysis and clinical evaluation of collected data; Conduct in-depth investigations on identified providers; Examine claims for compliance with billing and processing guidelines; Review and conduct retrospective analysis of claims and medical records prior to payment; Research new healthcare-related questions to aid investigations; Collaborate with the Special Investigation Unit and other internal areas; Recommend possible interventions for loss control and risk avoidance.
Seniority
Mid-level, hands-on IC