Clinical Investigator, SIU

📋 Description

• Detect and audit aberrant billing patterns in claims and records.
• Pre- and post-payment reviews of medical records for guideline/CMS compliance.
• Analyze provider behavior to identify cloning, upcoding, and unbundling.
• Translate audit findings into education for Oscar teams.
• Facilitate discussions with providers to correct billing and promote compliance.
• Build evidentiary files for recovery or referrals.

🎯 Requirements

• Active, unrestricted RN license.
• 3+ years direct patient care clinical experience.
• 2+ years in Medical Review, Utilization Management, or CDI with forensic guidelines (MCG, CMS).
• Experience conducting forensic medical audits to validate CPC/HCPCS/ICD-10 codes.
• BSN/ADN with related degree or 5+ years specialized audit exp.
• Experience delivering provider feedback in a professional manner.

🎁 Benefits

• Medical, dental, and vision benefits.
• 11 paid holidays, paid sick time, parental leave.
• 401(k) participation with company contributions.
• Life and disability insurance.
• Unlimited vacation program and annual performance bonuses.