Clinical Investigator II at BMC Software

Job description

POSITION SUMMARY : Operating under general direction from the SIU Director, the Clinical Investigator II serves as the Special Investigations Unit’s clinical subject matter expert responsible for identifying, investigating, and preventing healthcare fraud, waste, and abuse (FWA). Exercising independent judgment, this role evaluates clinical medical necessity, leads complex provider investigations and medical audits, and collaborates with regulatory agencies and law enforcement. The position routes key deliverables through Director approval, has no direct reports, and exists to safeguard plan assets and ensure quality member care. Position : Clinical Investigator Department : BMCHP Compliance Schedule : Full Time ESSENTIAL RESPONSIBILITIES / DUTIES: Leads clinically complex FWA investigations, including medical record audits (on-site and desk) and provider and member interviews, to determine whether services are supported, medically necessary and properly documented. Prepares investigative reports with findings, corrective action recommendations, and agency referrals, and maintains accurate, timely records in Case Shield and departmental FWA databases. Partners with internal departments (e.g., Claims, Medical Management, Legal, Provider Relations) to implement corrective actions such as provider education, prepayment review, payment suspension, and overpayment recovery; manages corrective action and repayment plans and processes claims in SIU pend queues. Serves as the SIU's clinical resource, answering clinical questions from investigators and the team on medical necessity, coverage policies, and documentation. Triages incoming referrals and allegations using clinical judgment, claims, and prescribing data to determine the investigative pathway and identify high-risk or medically unnecessary services and outlier providers, pharmacies, and members. Conducts data mining and analyzes anti-fraud platform intelligence to identify potential FWA and helps refine clinical detection algorithms. Supports law enforcement investigations and prosecutions, including testimony, and prepares regulatory reports and subpoena responses. Serves as one of the Plan's points of contact with NH and/or MA state agencies and as a liaison for vendor FWA activities, keeping the SIU Director informed of regulatory, vendor, and investigative developments. (The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required). JOB REQUIREMENTS REQUIRED EDUCATION AND EXPERIENCE: 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. PREFERRED EDUCATION AND EXPERIENCE: Advanced degree in Nursing or related clinical discipline (e.g., MSN, PA, PharmD, DPT, or other healthcare-related master’s degree). Experience in managed care, including Medicaid Managed Care and Medicaid fraud detection functions such as an SIU, Program Integrity Unit, RAC, or MFCU. Clinical experience in a behavioral health setting. Experience with Facets claims processing, external auditing, medical record review, or claims processing. CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED: Clinical licensure in Massachusetts or New Hampshire (e.g. APRN, RPh, LICSW, LMHC, PharmD, RN) Professional certification in healthcare fraud investigation or examination, including Accredited Health Care Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), or Health Care Anti-Fraud Associate (HCAFA) required within 12 months of start date. CERTIFICATES, LICENSES, REGISTRATIONS PREFERRED: Healthcare coding certification (e.g., CPC, CCS, or CCS-P.) KNOWLEDGE, SKILLS & ABILITIES (KSAs): Proficiency with Microsoft Off