Senior Analyst, SIU Clinical Investigator

📋 Description

• Detect and audit aberrant billing patterns within claims and clinical docs using forensic clinical
• Perform pre-payment and post-payment reviews to ensure billed services align with guidelines, CMS
• Analyze provider behavior to identify schemes like record cloning, upcoding, and unbundling.
• Translate audit findings into education and facilitate discussions to correct billing behaviors.
• Partner with investigators to build evidentiary files for recovery, legal action, or referrals.
• Report into the Investigations Manager, SIU.

🎯 Requirements

• Active, unrestricted Registered Nurse (RN) license.
• 3+ years of direct patient care clinical experience; Case Management a bonus.
• 2+ years in Medical Review, Utilization Management, or Clinical Documentation Improvement with
• Experience conducting forensic medical audits showing that narrative supports CPC/HCPCS/ICD-10

🎁 Benefits

• Competitive base pay and annual performance bonuses.
• Eligibility for Oscar’s unlimited vacation program.
• Comprehensive benefits (medical, dental, vision) and 401(k).
• Hybrid/remote work options with occasional in-office days as needed.