Clinical Investigator, SIU

Atlanta, GA - USA

Yearly Salary: $ 64832 - 85092

Posted on: 6 hours ago

Vacancies: 1 Vacancy

Job Summary

Hi were Oscar. Were hiring a Senior Analyst Special Investigations Unit Clinical Investigator to join our SIU.

Oscar is the first health insurance company built around a full stack technology platform and a relentless focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselvesone that behaves like a doctor in the family.

About the role:

The Senior Analyst SIU Clinical Investigator detects and audits aberrant billing patterns within claims and clinical documentation using forensic clinical expertise to protect the integrity of healthcare spend. You will perform comprehensive pre-payment and post-payment reviews of medical records to ensure billed services align with established clinical guidelines CMS regulations and contractual obligations. Beyond individual claim accuracy you will analyze provider behavior to identify schemes such as record cloning upcoding and unbundling that may be invisible to automated systems. As a clinical subject matter expert you will act to translate audit findings into relevant education. You will facilitate professional discussions with colleagues and providers to correct billing behaviors and promote long-term compliance. You will partner with clinical and non-clinical investigators to build evidentiary files for potential recovery legal action or referrals to appropriate outside agencies.

You will report into the Investigations Manager SIU.

Work Location: This is a remote position open to candidates who reside in: Arizona; Florida; Georgia; or Texas. While your daily work will be completed from your home office occasional travel may be required for team meetings and company events. #LI-Remote

Pay Transparency: The base pay for this role is: $64832 - $85092 per year. You are also eligible for employee benefits participation in Oscars unlimited vacation program and annual performance bonuses.

Responsibilities:

Identify and conduct clinical audits into suspected FWA with high autonomy
Document findings to include formal reports graphs audit logs and other supporting documentation.
Metrics to align with unit goals.
Participate in the development and presentation of FWA-related education for Oscar teams
Compliance with all applicable laws and regulations
Other duties as assigned

Requirements:

Active unrestricted Registered Nurse (RN) license
3 years of direct patient care clinical experience. Case Management experience a bonus.
2 years of experience in Medical Review Utilization Management or Clinical Documentation Improvement featuring demonstrated expertise in the forensic application of complex clinical guidelines (e.g. MCG CMS and specialty-specific professional organizations) to multifaceted medical records.
Experience conducting forensic medical audit with a focus on validating that clinical narrative supports the specificity and necessity of billed CPC HCPCS and ICD-10 codes.

Bonus points:

Bachelor of Science in Nursing (BSN) Associate Degree in Nursing (ADN) with a Bachelor of Science in Health Administration Clinical Informatics or a related Medical Science field or Associate Degree in Nursing (ADN) with 5 years of specialized clinical audit experience.
Experience working in health insurance with competency regarding claims processing billing reimbursement or provider contracting.
Experience delivering feedback or education to providers/physicians in a professional non-confrontational and persuasive manner.
Identifying trends for example cloned documentation or change in billing habits of a provider.
Experience with HIPAA data privacy and/or data security processes
Certified Case Manager (CCM) Certified Professional Coder (CPC) Certified Professional Medical Auditor (CPMA) Certified Fraud Examiner (CFE) Accredited Healthcare Fraud Investigator (AHFI) or similar.

This is an authentic Oscar Health job opportunity. Learn more about how you can safeguard yourself from recruitment fraud here.

At Oscar being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves and find both belonging and support. Were on a mission to change health care -- an experience made whole by our unique backgrounds and perspectives.

Pay Transparency: Final offer amounts within the base pay set forth above are determined by factors including your relevant skills education and experience. Full-time employees are eligible for benefits including: medical dental and vision benefits 11 paid holidays paid sick time paid parental leave 401(k) plan participation life and disability insurance and paid wellness time and reimbursements.

Artificial Intelligence (AI): Our AI Guidelines outline the acceptable use of artificial intelligence for candidates and detail how we use AI to support our recruiting efforts.

Reasonable Accommodation: Oscar applicants are considered solely based on their qualifications without regard to applicants disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team () to make the need for an accommodation known.

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Hi were Oscar. Were hiring a Senior Analyst Special Investigations Unit Clinical Investigator to join our SIU.Oscar is the first health insurance company built around a full stack technology platform and a relentless focus on serving our members. We started Oscar in 2012 to create the kind of health...