Clinical Investigator

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Quick Summary

Key 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.

Requirements Summary

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,

Technical Tools

OtherInvestigator

Hi, we're Oscar. We're 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 ourselves—one that behaves like a doctor in the family.

About the Role

~1 min read

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.

Responsibilities

~1 min read

→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

~1 min read

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.

Nice to Have

~2 min read

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. We're 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.

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