Clinical Investigator • Senior

Who you are

You have a strong background in clinical investigations and auditing, with a focus on detecting aberrant billing patterns within healthcare claims. Your forensic clinical expertise allows you to protect the integrity of healthcare spending, ensuring that billed services align with established clinical guidelines and regulations. You are skilled in performing comprehensive pre-payment and post-payment reviews of medical records, and you understand the nuances of CMS regulations and contractual obligations. Your analytical skills enable you to identify schemes such as record cloning, upcoding, and unbundling that may be invisible to automated systems.

As a clinical subject matter expert, you excel at translating audit findings into relevant education for colleagues and providers. You are comfortable facilitating professional discussions to correct billing behaviors and promote long-term compliance. Your collaborative nature allows you to partner effectively with both clinical and non-clinical investigators, building evidentiary files for potential recovery, legal action, or referrals to appropriate outside agencies. You thrive in environments where you can leverage your expertise to drive positive change in healthcare practices.

What you'll do

In this role, you will be responsible for detecting and auditing aberrant billing patterns within claims and clinical documentation. You will conduct thorough pre-payment and post-payment reviews of medical records, ensuring that billed services align with established clinical guidelines and CMS regulations. Your work will involve analyzing provider behavior to identify potential schemes that could compromise the integrity of healthcare spending.

You will act as a clinical subject matter expert, translating your audit findings into educational resources for colleagues and providers. Facilitating discussions with healthcare providers to correct billing behaviors will be a key part of your responsibilities, as will promoting long-term compliance with clinical guidelines. You will collaborate with both clinical and non-clinical investigators to build evidentiary files that may be used for potential recovery or legal action.

Your role will also involve reporting to the Investigations Manager, SIU, and contributing to the overall mission of Oscar to create a health insurance company that prioritizes the well-being of its members. You will work remotely, with the opportunity to connect with colleagues across various states, including Arizona, Florida, Georgia, and Texas.

What we offer

Oscar is committed to creating a supportive and inclusive work environment. As a remote position, you will have the flexibility to work from home while still being part of a dynamic team. We value the contributions of our employees and strive to provide opportunities for professional growth and development. Our mission is to transform the healthcare experience for our members, and we encourage you to apply even if your experience doesn't match every requirement. Join us in making a difference in the healthcare industry.