Clinical Investigator I (Special Investigation Unit) (Healthcare Fraud)

Location: Remote in Missouri, United States

Company

hirify.global provides healthcare services focused on improving access to care for individuals, families, and communities.

What you will do

• Perform retrospective and prepayment reviews of medical records to identify potential fraud, abuse, and inappropriate billing.
• Analyze claims data, medical records, billing codes, provider history, regulations, and company policies.
• Investigate provider billing patterns and recommend appropriate payment and next steps.
• Prepare findings summaries and recommendations for providers and internal stakeholders.
• Recommend policy, procedure, and provider-practice changes to prevent future fraudulent or erroneous billing.
• Consult with investigators by applying clinical and coding expertise to billing activity analysis.

Requirements

• Associate's degree in a related field or equivalent experience preferred.
• At least 2 years of related clinical experience in the field of the obtained license required.
• Required license or certification: accredited coding certification, RN, LPC, LPN, LCSW, LMHC, PT, OT, ST, or a related license.
• Experience with CPT coding, nurse coding, or provider education is preferred.
• Ability to review clinical documentation, claims, billing patterns, regulatory requirements, and practice standards.

Culture & Benefits

• Remote, hybrid, field, and office work schedules are supported, with this role listed as remote in Missouri.
• Health insurance and competitive pay.
• 401(k) and stock purchase plans.
• Tuition reimbursement, paid time off, and holidays.
• Compensation is adjusted based on skills, experience, education, job-related factors, and employment status.