Clinical Investigator II

🔥 12 hours ago

🗻 New Hampshire, Massachusetts – Remote

🗻 New Hampshire – Remote 🍂 Massachusetts – Remote

💵 $78k - $113k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Boston Medical Center (BMC)

WebsiteLinkedInAll Job Openings

5001 - 10000 employees

Founded 1996

Boston Medical Center (BMC) is a 511-bed, equity-led academic medical center and a proud member of the Boston Medical Center Health System. BMC delivers a model of healthcare where innovative and equitable care empowers all patients to thrive. As a premier academic medical center in Boston, a national leader in clinical care, and the largest essential hospital in New England, BMC’s world-class clinicians provide comprehensive care in more than 70 specialties and subspecialties.

📋 Description

• Lead clinically complex fraud, waste, and abuse investigations, including medical record audits and provider/member interviews • Prepare investigative reports, corrective action recommendations, agency referrals, and regulatory submissions • Maintain timely records in Case Shield and departmental FWA databases • Partner with Claims, Medical Management, Legal, and Provider Relations on corrective actions, payment suspension, overpayment recovery, and repayment plans • Process claims in SIU pend queues • Serve as the SIU clinical resource on medical necessity, coverage policies, and documentation • Triage referrals and allegations using clinical judgment, claims, and prescribing data • Conduct data mining and analyze anti-fraud platform intelligence to identify FWA and refine clinical detection algorithms • Support law enforcement investigations and prosecutions, including testimony • Serve as a point of contact with New Hampshire and/or Massachusetts state agencies and liaise with vendor FWA activities • Keep the SIU Director informed of regulatory, vendor, and investigative developments

🎯 Requirements

• Bachelor's degree in nursing and five years of experience in a healthcare payer environment, healthcare fraud control, or a comparable investigative role, case management, utilization review, or claims auditing; or equivalent combination of education and experience • Clinical licensure in Massachusetts or New Hampshire (e.g. APRN, RPh, LICSW, LMHC, PharmD, RN) • Professional certification in healthcare fraud investigation or examination, including AHFI, CFE, or HCAFA, required within 12 months of start date • Proficiency with Microsoft Office, including Excel pivot tables • Ability to develop investigative strategies for complex, clinically sensitive fraud cases • Strong verbal and written communication skills • Ability to review, proofread, and edit investigative reports and regulatory submissions • Ability to aggregate, triangulate, and evaluate data from clinical records, claims history, and provider billing patterns • Foundational understanding of CPT, ICD-10-CM, and HCPCS coding methodologies • Advanced degree in Nursing or related clinical discipline preferred • Experience in managed care, Medicaid Managed Care, Medicaid fraud detection, behavioral health, Facets claims processing, external auditing, medical record review, or claims processing preferred • Healthcare coding certification such as CPC, CCS, or CCS-P preferred

🏖️ Benefits

• Medical, dental, vision, and pharmacy benefits • Discretionary annual bonuses • Merit increases • Flexible Spending Accounts • 403(b) savings matches • Paid time off • Career advancement opportunities • Resources to support employee and family well-being

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