Clinical Investigator

ABOUT THE ROLE We are hiring a Clinical Investigator to join our Special Investigations Unit (SIU) at Oscar. As a Clinical Investigator, you will play a critical role in detecting and auditing aberrant billing patterns within claims and clinical documentation to protect the integrity of healthcare spend. You will use your forensic clinical expertise to identify schemes such as record cloning, upcoding, and unbundling that may be invisible to automated systems. WHAT YOU'LL DO As a Clinical Investigator, you will be responsible for conducting comprehensive pre-payment and post-payment reviews of medical records to ensure billed services align with established clinical guidelines, CMS regulations, and contractual obligations. You will analyze provider behavior to identify potential schemes and partner with clinical and non-clinical investigators to build evidentiary files for potential recovery, legal action, or referrals to outside agencies. You will also facilitate professional discussions with colleagues and providers to correct billing behaviors and promote long-term compliance. WHAT YOU'LL NEED To be successful in this role, you will need to have an active, unrestricted Registered Nurse (RN) license and at least 3 years of direct patient care clinical experience, with experience in Medical Review, Utilization Management, or Clinical Documentation Improvement. You will also need to have demonstrated expertise in the forensic application of complex clinical guidelines to multifaceted medical records. Experience conducting forensic medical audits and delivering feedback or education to providers/physicians in a professional manner is also highly desirable. WHY REMOTE This is a remote position, open to candidates who reside in Arizona, Florida, Georgia, Illinois, Iowa, Kansas, Michigan, Missouri, Nebraska, New Jersey, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, and Virginia. While our approach to work may adapt over time, you will be fully remote, with the possibility of a hybrid presence at the hub office associated with your metro area. BENEFITS The base pay for this role is $67,813 - $89,004 per year, with a higher salary range of $75,348 - $98,894 per year for candidates residing in New Jersey and New York. You are also eligible for employee benefits, participation in Oscar's unlimited vacation program, and annual performance bonuses.