Licensed Investigative Clinician

A company is looking for an Investigative Clinician - Insurance Claims. Key Responsibilities : Conduct thorough reviews of medical records, treatment plans, and billing documentation Identify patterns of overutilization, upcoding, or potential fraud and abuse Prepare clear, detailed, and objective clinical summary reports with findings and recommendations Required Qualifications : Active U.S. license as a healthcare professional (RN, NP, MD, or equivalent) At least 3-5 years of hands-on clinical experience Prior work experience in insurance claims review, utilization management, or healthcare fraud investigation preferred Proficient in reviewing electronic health records (EHRs), ICD-10, CPT coding, and medical billing practices Certification in fraud investigation is preferred