Clinical Investigator, SIU
About The Position
The Senior Analyst, SIU Clinical Investigator detects and audits aberrant billing patterns within claims and clinical documentation, using forensic clinical expertise to protect the integrity of healthcare spend. You will perform comprehensive pre-payment and post-payment reviews of medical records to ensure billed services align with established clinical guidelines, CMS regulations, and contractual obligations. Beyond individual claim accuracy, you will analyze provider behavior to identify schemes such as record cloning, upcoding, and unbundling that may be invisible to automated systems. As a clinical subject matter expert, you will act to translate audit findings into relevant education. You will facilitate professional discussions with colleagues and providers to correct billing behaviors and promote long-term compliance. You will partner with clinical and non-clinical investigators to build evidentiary files for potential recovery, legal action, or referrals to appropriate outside agencies. You will report into the Investigations Manager, SIU.
Requirements
- Active, unrestricted Registered Nurse (RN) license
- 3+ years of direct patient care clinical experience. Case Management experience a bonus.
- 2+ years of experience in Medical Review, Utilization Management, or Clinical Documentation Improvement, featuring demonstrated expertise in the forensic application of complex clinical guidelines (e.g., MCG, CMS, and specialty-specific professional organizations) to multifaceted medical records.
- Experience conducting forensic medical audit with a focus on validating that clinical narrative supports the specificity and necessity of billed CPC, HCPCS, and ICD-10 codes.
Nice To Haves
- Bachelor of Science in Nursing (BSN), Associate Degree in Nursing (ADN) with a Bachelor of Science in Health Administration, Clinical Informatics, or a related Medical Science field, or Associate Degree in Nursing (ADN) with 5+ years of specialized clinical audit experience.
- Experience working in health insurance with competency regarding claims processing, billing, reimbursement, or provider contracting.
- Experience delivering feedback or education to providers/physicians in a professional, non-confrontational, and persuasive manner.
- Identifying trends, for example “cloned documentation” or change in billing habits of a provider.
- Experience with HIPAA, data privacy, and/or data security processes
- Certified Case Manager (CCM), Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or similar.
Responsibilities
- Identify and conduct clinical audits into suspected FWA with high autonomy
- Document findings, to include formal reports, graphs, audit logs, and other supporting documentation. Metrics to align with unit goals.
- Participate in the development and presentation of FWA-related education for Oscar teams
- Compliance with all applicable laws and regulations
- Other duties as assigned
Benefits
- employee benefits
- participation in Oscar's unlimited vacation program
- annual performance bonuses
- medical, dental, and vision benefits
- 11 paid holidays
- paid sick time
- paid parental leave
- 401(k) plan participation
- life and disability insurance
- paid wellness time and reimbursements
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
