State Licensed Investigative Clinician

Job Summary

A company is looking for an Investigative Clinician - Insurance Claims.

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
• Provide clinical expertise to claims investigators and legal personnel regarding questionable claims

Required Qualifications

• Active U.S. license as a healthcare professional (RN or NP)
• 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
• Certification in fraud investigation is preferred