Investigative Clinician – Insurance Claims

Job description

Overview Experienced Investigative Clinician - Insurance Claims Remote: Are you a licensed healthcare professional( RN or NP) with a passion for uncovering the truth behind medical claims? We’re seeking an experienced Investigative Clinician to join our team and support a major national client in evaluating the medical validity of insurance claims. This role blends clinical expertise with investigative acumen to detect, prevent, and resolve fraudulent, exaggerated, or non-medically necessary claims. As an integral member of the Special Investigations Unit (SIU), you’ll collaborate closely with adjusters, legal teams, and investigators to analyze medical documentation and uncover inconsistencies or red flags. If you thrive in a fast-paced, analytical environment and want to make a real impact in the fight against insurance fraud, we want to hear from you. Responsibilities/ Requirements: Key Responsibilities: - Conduct thorough reviews of medical records, treatment plans, and billing documentation to assess accuracy, consistency, and medical necessity. - Identify patterns of overutilization, upcoding, or potential fraud and abuse. - Provide clinical expertise to claims investigators,...