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 medical record assessments and interviews with providers and members.

• Draft investigative reports, propose corrective actions, make agency referrals, and handle regulatory submissions.

• Ensure timely documentation in Case Shield and departmental fraud, waste, and abuse databases.

• Collaborate with Claims, Medical Management, Legal, and Provider Relations on implementing corrective measures, suspending payments, recovering overpayments, and establishing repayment plans.

• Manage claims within the Special Investigations Unit (SIU) pending queues.

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

• Assess and prioritize referrals and allegations using clinical judgment, claims data, and prescribing information.

• Perform data mining and analyze insights from anti-fraud platforms to detect fraud, waste, and abuse while enhancing clinical detection algorithms.

• Assist law enforcement with investigations and prosecutions, which may include providing testimony.

• Serve as a liaison with New Hampshire and/or Massachusetts state agencies and coordinate with vendor fraud activities.

• Keep the SIU Director updated on regulatory matters, vendor issues, and investigative progress.

⛳️ Requirements

• A bachelor's degree in nursing along with five years of experience in a healthcare payer setting, healthcare fraud control, or a similar investigative role, case management, utilization review, or claims auditing; or an equivalent combination of education and experience.

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

• 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, especially with Excel pivot tables.

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

• Excellent verbal and written communication skills.

• Competence to review, proofread, and edit investigative reports and regulatory submissions.

• Ability to aggregate, triangulate, and assess data from clinical records, claims history, and provider billing patterns.

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

• An advanced degree in Nursing or a related clinical field is preferred.

• Experience in managed care, Medicaid Managed Care, Medicaid fraud detection, behavioral health, Facets claims processing, external auditing, medical record review, or claims processing is preferred.

• Healthcare coding certification such as CPC, CCS, or CCS-P is preferred.

🏝️ Benefits

• Medical, dental, vision, and pharmacy benefits.

• Discretionary annual bonuses.

• Merit-based salary increases.

• Flexible Spending Accounts.

• 403(b) retirement savings matches.

• Paid time off.

• Opportunities for career advancement.

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