Clinical Fraud Investigator - Health Plan Audits

Automatic Data Processing, Inc.; Elkridge (MD); On-site; USD 90,000 - 130,000; Full time

Job summary

APWU Health Plan is seeking a FWA Clinical Investigator to join the Finance & Admin Services division in Elkridge, MD. The role audits clinical documentation and healthcare claims to identify billing irregularities and ensure accuracy, supporting overpayment recoveries and provider actions.

The ideal candidate has an associate or bachelor’s degree in a health field, 5+ years of clinical documentation review experience, and proficiency with MS Office 365.

Qualifications

• Associate or bachelor’s degree in health information management, Nursing, Healthcare Administration, Medical Coding, Criminal Justice or related healthcare field.
• Five plus years of experience performing clinical documentation reviews.
• Experience with fraud, waste and abuse investigations, claims auditing of medical and behavioral health services and utilization review.
• Certifications preferred: CPC, CCS, RHIA, CPMA.
• Proficiency with Microsoft Office 365 including Excel, PowerPoint, Outlook, SharePoint and Word.
• Knowledge of HIPAA, OPM/OIG guidelines, CMS regulations.
• Experience with EMR/HER systems and claims processing systems; data analysis and reporting tools.
• Ability to define data and information needs; analyze data relative to healthcare utilization.
• Ability to identify documentation inconsistencies and billing irregularities.
• Knowledge of CPT and ICD10 coding; investigative techniques; analytics; insurance and claim operations.
• Highly organized, analytical, with strong problem solving and communication skills.

Responsibilities

• Review EMRs, clinical notes, itemized bills, and provider documentation for validity and clinical justification of billed services.
• Analyze complex healthcare claims data to uncover suspicious provider billing behaviors.
• Draft evidence-based audit summaries, case briefs, and clinical rationales to support overpayment recoveries or referrals.
• Partner with investigators and data analysts to build evidence files for fraud investigations.
• Serve as clinical subject matter expert for non-clinical investigators, translating clinical workflows into actionable leads.
• Perform other duties as assigned.

Skills

Data analysis

Attention to detail

Analytical thinking

Verbal and written communication

Investigative techniques

Education

Associate or bachelor’s degree in health information management or related healthcare field

Tools

Microsoft Office 365 Suite

Job description

APWU Health Plan is seeking a FWA Clinical Investigator to join the Finance & Admin Services division in Elkridge, MD. The role audits clinical documentation and healthcare claims to identify billing irregularities and ensure accuracy, supporting overpayment recoveries and provider actions.

The ideal candidate has an associate or bachelor’s degree in a health field, 5+ years of clinical documentation review experience, and proficiency with MS Office 365.