Clinical Investigator, SIU

Job Overview

As a Clinical Investigator at SIU, you will be responsible for identifying and auditing aberrant billing patterns in claims, reviewing medical records for guideline alignment, analyzing provider behavior, translating audit findings into education, and building evidentiary files for recovery or legal action.

Responsibilities

• Identify and audit aberrant billing patterns in claims
• Review pre-/post-payment medical records for guideline alignment
• Analyze provider behavior for cloning, upcoding, and unbundling
• Translate audit findings into education for Oscar teams
• Build evidentiary files for recovery, legal action, or referrals

Requirements & Qualifications

• Active, unrestricted RN license
• 3+ years direct patient care clinical experience
• 2+ years in Medical Review/Utilization Management/CDI with forensic focus
• Experience conducting forensic medical audits validating CPC/HCPCS/ICD-10 codes