Remote Clinical Fraud Investigator (RN/CPC)

Elevance Health; Woburn (MA); Remote; USD 65,968 - 124,992; Full time

Job summary

A healthcare services provider is seeking a Clinical Fraud Investigator II, requiring an Associate Degree in Nursing and CPC certification. Responsibilities include analyzing clinical data, investigating claims for compliance, and collaborating with internal teams. Candidates must have at least 4 years of experience in healthcare, including 1 year in clinical fraud investigation. This role offers remote work flexibility within certain commuting distances and a salary range of $65,968 to $124,992 depending on experience.

Qualifications

• Minimum of 4 years related experience in healthcare.
• At least 1 year experience in Clinical Fraud Investigation.

Responsibilities

• Perform comprehensive analysis and clinical evaluation of data.
• Investigate identified providers as warranted.
• Examine claims for compliance with billing guidelines.
• Conduct analysis of claims and medical records before payment.
• Collaborate with the Special Investigation Unit on mutual concerns.
• Recommend interventions for loss control based on investigations.

Skills

Clinical Evaluation

Fraud Prevention

Patient Billing Compliance

Collaboration

Education

Associate Degree in Nursing

Certified Professional Coder (CPC)

Job description

A healthcare services provider is seeking a Clinical Fraud Investigator II, requiring an Associate Degree in Nursing and CPC certification. Responsibilities include analyzing clinical data, investigating claims for compliance, and collaborating with internal teams. Candidates must have at least 4 years of experience in healthcare, including 1 year in clinical fraud investigation. This role offers remote work flexibility within certain commuting distances and a salary range of $65,968 to $124,992 depending on experience.