Senior Clinical Investigator Consultant

Job Summary

A company is looking for a Senior Clinical Investigative Consultant, Meritain (TPA)-Remote.

Key Responsibilities

• Review provider medical records for clinical appropriateness and coding compliance
• Conduct complex investigations into suspected fraud, waste, and abuse (FWA) and prepare findings for stakeholders
• Mentor teammates and collaborate with various teams on special investigations and coding-related inquiries

Required Qualifications

• Experience in medical record auditing and coding
• Knowledge of state and federal healthcare guidelines and policies
• Ability to conduct high-level investigations into healthcare fraud
• Experience in preparing written case summaries and documentation
• Ability to provide testimony in criminal or civil proceedings