Clinical Investigator II

BMC Software

12d•$78,000 - $113,000

About The Position

Operating under general direction from the SIU Director, the Clinical Investigator II serves as the Special Investigations Unit’s clinical subject matter expert responsible for identifying, investigating, and preventing healthcare fraud, waste, and abuse (FWA). The role uses independent judgment to evaluate clinical medical necessity, lead complex provider investigations and medical audits, and collaborate with regulatory agencies and law enforcement. Key deliverables are routed through Director approval. The position has no direct reports and supports the protection of plan assets and quality member care. The role is within BMCHP Compliance and is full-time. Responsibilities include clinical FWA investigations and audits, investigative reporting and recordkeeping, coordination of corrective actions and repayment plans, clinical guidance to the SIU, referral triage, data analysis, law enforcement and regulatory support, and liaison work with state agencies and vendors. The duties listed are not exhaustive.

Requirements

Bachelor's degree in nursing and five years of experience in a healthcare payer environment, healthcare fraud control, a comparable investigative role, case management, utilization review, or claims auditing; or an equivalent combination of education and experience.
Clinical licensure in Massachusetts or New Hampshire, such as APRN, RPh, LICSW, LMHC, PharmD, or RN.
Professional certification in healthcare fraud investigation or examination, such as AHFI, CFE, or HCAFA, required within 12 months of the start date.
Proficiency with Microsoft Office, including Excel pivot tables.
Ability to develop investigative strategies for complex, clinically sensitive fraud cases.
Strong verbal and written communication skills to present investigative findings and exchange information with internal and external audiences.
Ability to review, proofread, and edit investigative reports and regulatory submissions for accuracy and completeness.
Ability to aggregate, triangulate, and evaluate data from disparate sources, including clinical records, claims history, and provider billing patterns.
Foundational understanding of CPT, ICD-10-CM, and HCPCS coding methodologies.

Nice To Haves

Advanced degree in Nursing or a related clinical discipline, such as MSN, PA, PharmD, DPT, or another healthcare-related master's degree.
Experience in managed care, including Medicaid Managed Care and Medicaid fraud detection functions such as an SIU, Program Integrity Unit, RAC, or MFCU.
Clinical experience in a behavioral health setting.
Experience with Facets claims processing, external auditing, medical record review, or claims processing.
Healthcare coding certification, such as CPC, CCS, or CCS-P.

Responsibilities

Lead clinically complex FWA investigations, including on-site and desk medical record audits and provider and member interviews, to assess whether services are supported, medically necessary, and properly documented.
Prepare investigative reports containing findings, corrective-action recommendations, and agency referrals, and maintain accurate, timely records in Case Shield and departmental FWA databases.
Partner with Claims, Medical Management, Legal, Provider Relations, and other internal departments to implement corrective actions, including provider education, prepayment review, payment suspension, and overpayment recovery.
Manage corrective-action and repayment plans and process claims in SIU pend queues.
Serve as the SIU clinical resource by answering questions from investigators and team members about medical necessity, coverage policies, and documentation.
Triage incoming referrals and allegations using clinical judgment, claims, and prescribing data to determine investigative pathways and identify high-risk or medically unnecessary services and outlier providers, pharmacies, and members.
Conduct data mining and analyze anti-fraud platform intelligence to identify potential FWA and help refine clinical detection algorithms.
Support law enforcement investigations and prosecutions, including testimony, and prepare regulatory reports and subpoena responses.
Serve as a Plan point of contact with New Hampshire and/or Massachusetts state agencies and as a liaison for vendor FWA activities.
Keep the SIU Director informed of regulatory, vendor, and investigative developments.