Clinical Investigator II

This is a fully remote position, open to applicants in New Hampshire, +1 more state.

📋 Description

• Oversee intricate investigations related to fraud, waste, and abuse, which include auditing medical records and conducting interviews with providers and members.

• Draft comprehensive investigative reports, suggestions for corrective actions, referrals to agencies, and submissions to regulatory bodies.

• Ensure precise record-keeping in Case Shield and the department's FWA databases.

• Collaborate with Claims, Medical Management, Legal, and Provider Relations teams to execute corrective measures.

• Oversee corrective actions and repayment strategies while processing claims in SIU pending queues.

• Act as the clinical resource for SIU on topics such as medical necessity, coverage policies, and documentation standards.

• Assess referrals and allegations using clinical insight, claims, and prescribing information.

• Perform data mining and evaluate intelligence from anti-fraud platforms.

• Assist with law enforcement investigations and prosecutions, including providing testimony when necessary.

• Serve as a liaison with state agencies in New Hampshire and/or Massachusetts and coordinate with FWA vendors.

⛳️ Requirements

• A Bachelor’s degree in nursing and a minimum of five years of experience within a healthcare payer setting, healthcare fraud prevention, or a related investigative position, case management, utilization review, or claims auditing; or a suitable combination of education and experience.

• Possession of clinical licensure in Massachusetts or New Hampshire (e.g. APRN, RPh, LICSW, LMHC, PharmD, RN).

• A professional certification in healthcare fraud investigation or examination, such as AHFI, CFE, or HCAFA, is required within 12 months from the start date.

• Proficiency in Microsoft Office applications, particularly with Excel pivot tables.

• Capability to formulate investigative strategies for complex and clinically sensitive fraud cases.

• Excellent verbal and written communication skills.

• Proficient in reviewing, proofreading, and editing investigative reports and regulatory submissions.

• Competence in aggregating, triangulating, and assessing data from various sources.

• Basic understanding of CPT, ICD-10-CM, and HCPCS coding methodologies.

🏝️ Benefits

• Comprehensive medical, dental, vision, and pharmacy benefits.

• Discretionary annual bonuses.

• Opportunities for merit increases.

• Flexible Spending Accounts.

• 403(b) savings matches.

• Paid time off.

• Opportunities for career advancement.

• Resources available to support the well-being of employees and their families.