Clinical Investigator - Billing Audit

Job Overview

As a Clinical Investigator at SIU, you will be responsible for detecting and auditing aberrant billing patterns in claims and records. You will conduct pre- and post-payment reviews of medical records to ensure guideline and CMS compliance. Analyzing provider behavior to identify cloning, upcoding, and unbundling will be a key focus. Your role involves translating audit findings into educational materials for Oscar teams, facilitating discussions with providers to correct billing practices, and building evidentiary files for recovery or referrals.

Responsibilities

• Detect and audit aberrant billing patterns in claims and records.
• Conduct pre- and post-payment reviews of medical records for guideline/CMS compliance.
• Analyze provider behavior to identify cloning, upcoding, and unbundling.
• Translate audit findings into education for Oscar teams.
• Facilitate discussions with providers to correct billing and promote compliance.
• Build evidentiary files for recovery or referrals.

Requirements & Qualifications

• Active, unrestricted RN license
• 3+ years direct patient care clinical experience
• 2+ years in Medical Review, Utilization Management, or CDI with forensic guidelines (MCG, CMS)
• Experience conducting forensic medical audits to validate CPC/HCPCS/ICD-10 codes
• BSN/ADN with related degree or 5+ years specialized audit experience
• Experience delivering provider feedback in a professional manner