Clinical Investigator II

About the role

The unit works on stopping improper payments and protecting plan assets while keeping member care sound. Reports go through the director, and the role has no direct reports.

At a glance

What you will do

• Lead complex fraud, waste and abuse investigations, including on-site and desk medical record audits
• Interview providers and members to check whether services were necessary and documented
• Write investigative reports with findings, corrective actions and referrals
• Work with claims, legal and provider relations on education, prepayment review, payment suspension and recovery
• Answer clinical questions from investigators on necessity, coverage and documentation
• Triage referrals using claims and prescribing data to pick the investigative path

What they look for

• Bachelor's degree in nursing plus five years in a payer, fraud control or similar investigative role, or equivalent
• Clinical licensure in Massachusetts or New Hampshire, such as APRN, RPh, LICSW, LMHC or PharmD

Nice to have

• Advanced clinical degree such as MSN, PA, PharmD or DPT
• Managed care experience, including Medicaid and program integrity work
• Behavioural health clinical background
• Facets claims processing or external auditing experience

A typical week

• Reviewing referrals and allegations and choosing how to investigate
• Auditing medical records and interviewing providers
• Writing reports and tracking cases in Case Shield
• Meeting internal departments on corrective actions and recovery
• Working with state agencies and fraud vendors