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[Remote] Clinical Investigator, SIU
Note: The job is a remote job and is open to candidates in USA. Oscar is a health insurance company focused on serving its members through a technology-driven platform. They are seeking a Senior Analyst for the Special Investigations Unit Clinical Investigator role, which involves detecting and auditing aberrant billing patterns, conducting clinical audits, and facilitating education to ensure compliance in healthcare billing practices.
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
Skills
- 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
- 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
Benefits
- Medical, dental, and vision benefits
- 11 paid holidays
- Paid sick time
- Paid parental leave
- 401(k) plan participation
- Life and disability insurance
- Paid wellness time and reimbursements
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