A company is looking for an Investigative Clinician - Insurance Claims.
Key Responsibilities :
Conduct thorough reviews of medical records, treatment plans, and billing documentation to assess accuracy and medical necessity
Identify patterns of overutilization, upcoding, or potential fraud and abuse
Prepare clear, detailed clinical summary reports with findings and recommendations
Required Qualifications :
Active U.S. license as a healthcare professional (RN, NP, MD, or equivalent)
At least 3-5 years of hands-on clinical experience
Prior experience in insurance claims review, utilization management, or healthcare fraud investigation preferred
Proficient in reviewing electronic health records (EHRs), ICD-10, CPT coding, and medical billing practices
Certification in fraud investigation is preferred
Licensed Clinician • Davie, Florida, United States