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 to assess accuracy and medical necessity

Identify patterns of overutilization, upcoding, or potential fraud and abuse

Prepare clear, detailed 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 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