Licensed Investigative Clinician

Job Summary

Seeking a licensed healthcare professional, the full-time remote Investigative Clinician will evaluate the medical validity of insurance claims by conducting thorough reviews of medical records, identifying patterns of potential fraud, and providing clinical expertise to stakeholders.

Key responsibilities:

• Conduct thorough reviews of medical records, treatment plans, and billing documentation to assess accuracy and medical necessity
• Identify patterns of overutilization, upcoding, or potential fraud and abuse
• Prepare detailed clinical summary reports with findings and recommendations

Required qualifications:

• Active U.S. license as a healthcare professional (RN, NP, MD, or equivalent)
• 3-5 years of hands-on clinical experience
• Prior experience in insurance claims review or healthcare fraud investigation preferred
• Proficient in reviewing electronic health records (EHRs) and medical billing practices
• Exceptional critical thinking and analytical skills