Investigative Clinician – Insurance Claims

Overview

Experienced Investigative Clinician - Insurance Claims

Remote

Are you a licensed healthcare professional( RN or NP) with a passion for uncovering the truth behind medical claims? We’re seeking an experienced Investigative Clinician to join our team and support a major national client in evaluating the medical validity of insurance claims. This role blends clinical expertise with investigative acumen to detect, prevent, and resolve fraudulent, exaggerated, or non-medically necessary claims.

As an integral member of the Special Investigations Unit (SIU), you’ll collaborate closely with adjusters, legal teams, and investigators to analyze medical documentation and uncover inconsistencies or red flags. If you thrive in a fast-paced, analytical environment and want to make a real impact in the fight against insurance fraud, we want to hear from you.

Responsibilities/ Requirements

Key Responsibilities:

• Conduct thorough reviews of medical records, treatment plans, and billing documentation to assess accuracy, consistency, and medical necessity.
• Identify patterns of overutilization, upcoding, or potential fraud and abuse.
• Provide clinical expertise to claims investigators, legal personnel, and other stakeholders in evaluating questionable claims.
• Interview claimants, healthcare providers, and related parties as needed to clarify details and verify medical facts.
• Prepare clear, detailed, and objective clinical summary reports with findings and recommendations.
• Deliver expert clinical opinions regarding treatment appropriateness and outcomes.
• Remain up-to-date with current clinical practices, fraud trends, billing guidelines, and relevant regulations.
• Participate in depositions or testify as a clinical expert in support of litigation efforts, when required.

Essentials for this Role:

• Active U.S. license as a healthcare professional (RN, NP, MD, or equivalent, no LPN's).
• At least 3–5 years of hands-on clinical experience.
• Prior work experience in insurance claims review, utilization management, or healthcare fraud investigation highly preferred.
• Proficient in reviewing electronic health records (EHRs), ICD-10, CPT coding, and medical billing practices.
• Exceptional critical thinking, detail orientation, and analytical skills.
• Strong verbal and written communication skills, including report writing.
• Ability to work independently and manage multiple concurrent assignments in a remote environment

Preferred Qualifications

• Certification in fraud investigation (e.g., Certified Fraud Examiner – CFE, Accredited Health Care Fraud Investigator – AHFI, or similar).
• Familiarity with claims management platforms and case tracking systems.
• Working knowledge of state and federal healthcare laws and insurance regulations.

Benefits

Compensation & Perks That Work For You:

We believe great work deserves great rewards. Here’s what you can expect when you join our team:

Benefits:

• Career development training
• Medical, Dental, Vision plans
• Life, LTD and STD paid by the employer
• 401(k) with company match
• Paid vacation
• Paid Paternity/Maternity Leave, after 1 year of service
• Tuition assistance after 1 year of service

The salary range for this role is between $80,000.00 - $110,000.00 annually.  This is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future.  An employee’s pay position within the salary range will be based on several factors including, but not limited to, relevant education, qualifications, certifications, experience, skills, geographic location, performance, and business or organizational needs.  

CoventBridge Group is an equal opportunity employer.  We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, caste, disability, veteran status, and other legally protected characteristics.

CoventBridge Group is committed to the full inclusion of all qualified individuals.  As part of this commitment, CoventBridge Group will ensure that persons with disabilities are provided reasonable accommodations. If reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact: Human Resources; 888-932-7364; [email protected]).