Investigative Clinician – Insurance 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. 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.