Clinical SIU Investigator

About the role

Our client is seeking an experienced SIU Clinical Investigator / Healthcare Compliance Professional to support a growing Special Investigations Unit (SIU). This role focuses on conducting clinical and compliance reviews of medical records to identify potential fraud, waste, abuse, and billing irregularities. The individual will serve as a subject matter expert, performing detailed reviews and analyses of complex healthcare claims and documentation.

Responsibilities

• Review medical records, claims, and supporting documentation for clinical consistency, completeness, and compliance.
• Identify potential indicators of fraud, waste, and abuse, including:
  • Cloning of medical documentation
  • Upcoding
  • Billing inconsistencies
  • Unsupported services and procedures
  • Medical necessity concerns
• Conduct initial reviews and assessments of complex healthcare cases to determine potential compliance risks.
• Analyze documentation to validate medical necessity and appropriateness of billed services.
• Collaborate with SIU investigators and leadership to support ongoing investigations.
• Document findings and provide clear recommendations for further review or action.
• Stay informed of healthcare regulations, billing guidelines, and industry best practices.

Requirements

• Experience in healthcare investigations, healthcare compliance, SIU, clinical auditing, utilization review, medical record review, or related healthcare oversight functions.
• Strong understanding of medical necessity criteria and healthcare documentation standards.
• Knowledge of healthcare fraud schemes, billing practices, and claims review methodologies.
• Experience reviewing complex medical records and identifying documentation discrepancies.
• Ability to analyze clinical information and communicate findings effectively.
• Clinical background strongly preferred.
• Experience in healthcare payer, managed care, SIU, fraud investigations, clinical auditing, or healthcare compliance environments is highly desirable.

Benefits

• Medical, Dental, Vision
• Life Insurance, Disability Insurance
• 401(k) Savings Plan
• Employee Stock Purchase Plan
• Professional Development Program
• Paid Time Off and Paid Sick Time (in geographies where legally required)

Compensation is commensurate with your qualifications, experience, and other factors including geographic location, market and operational factors.