Investigative Clinician – Insurance Claims

CoventBridge Group

4d•$80,000 - $110,000•Remote

About The Position

Experienced Investigative Clinician - Insurance Claims Remote Are you a licensed healthcare professional( RN or NP) with a passion for uncovering the truth behind medical claims? We’re seeking an experienced Investigative Clinician to join our team and support a major national client in evaluating the medical validity of insurance claims. This role blends clinical expertise with investigative acumen to detect, prevent, and resolve fraudulent, exaggerated, or non-medically necessary claims. As an integral member of the Special Investigations Unit (SIU), you’ll collaborate closely with adjusters, legal teams, and investigators to analyze medical documentation and uncover inconsistencies or red flags. If you thrive in a fast-paced, analytical environment and want to make a real impact in the fight against insurance fraud, we want to hear from you.

Requirements

Active U.S. license as a healthcare professional (RN, NP, MD, or equivalent, no LPN's).
At least 3–5 years of hands-on clinical experience.
Prior work experience in insurance claims review, utilization management, or healthcare fraud investigation highly preferred.
Proficient in reviewing electronic health records (EHRs), ICD-10, CPT coding, and medical billing practices.
Exceptional critical thinking, detail orientation, and analytical skills.
Strong verbal and written communication skills, including report writing.
Ability to work independently and manage multiple concurrent assignments in a remote environment

Nice To Haves

Certification in fraud investigation (e.g., Certified Fraud Examiner – CFE, Accredited Health Care Fraud Investigator – AHFI, or similar).
Familiarity with claims management platforms and case tracking systems.
Working knowledge of state and federal healthcare laws and insurance regulations.

Responsibilities

Conduct thorough reviews of medical records, treatment plans, and billing documentation to assess accuracy, consistency, and medical necessity.
Identify patterns of overutilization, upcoding, or potential fraud and abuse.
Provide clinical expertise to claims investigators, legal personnel, and other stakeholders in evaluating questionable claims.
Interview claimants, healthcare providers, and related parties as needed to clarify details and verify medical facts.
Prepare clear, detailed, and objective clinical summary reports with findings and recommendations.
Deliver expert clinical opinions regarding treatment appropriateness and outcomes.
Remain up-to-date with current clinical practices, fraud trends, billing guidelines, and relevant regulations.
Participate in depositions or testify as a clinical expert in support of litigation efforts, when required.