Senior Analyst, Special Investigations Unit Clinical Investigator

Location: Fully remote for candidates residing in Arizona, Florida, Georgia, Illinois, Iowa, Kansas, Michigan, Missouri, Nebraska, New Jersey, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, or Virginia. Candidates within commuting distance of the New York City or Tempe hub offices are expected to work onsite at least three days per week, including Thursdays.

Salary: $75,348–$98,894 per year in New Jersey and New York; $67,813–$89,004 per year in all other eligible locations.

Company

hirify.global is a health insurance company built around a full-stack technology platform and member-focused healthcare services.

What you will do

• Identify and conduct clinical audits into suspected fraud, waste, and abuse with a high degree of autonomy.
• Perform pre-payment and post-payment reviews of medical records against clinical guidelines, CMS regulations, and contractual requirements.
• Analyze provider behavior and detect patterns such as cloned documentation, upcoding, and unbundling.
• Prepare formal reports, graphs, audit logs, and supporting evidence for recovery, legal action, or external referrals.
• Partner with clinical and non-clinical investigators on evidentiary files and compliance activities.
• Develop and present fraud, waste, and abuse education for internal teams and providers.

Requirements

• Active, unrestricted Registered Nurse license.
• At least 3 years of direct patient-care clinical experience.
• At least 2 years of experience in medical review, utilization management, or clinical documentation improvement.
• Expertise applying complex clinical guidelines, including MCG, CMS, and specialty-specific standards, to multifaceted medical records.
• Experience conducting forensic medical audits and validating that clinical narratives support the specificity and necessity of CPC, HCPCS, and ICD-10 codes.

Nice to have

• BSN, or ADN combined with relevant bachelor-level education or 5+ years of specialized clinical audit experience.
• Health insurance experience involving claims processing, billing, reimbursement, or provider contracting.
• Experience educating providers and physicians in a professional and persuasive manner.
• Experience identifying documentation and billing trends, including cloned documentation and changing provider billing habits.
• HIPAA, data privacy, or data security experience; relevant professional certifications are also valued.

Culture & Benefits

• Full-time employment with medical, dental, and vision benefits.
• Unlimited vacation program, paid holidays, sick time, parental leave, and wellness time.
• 401(k) participation, life and disability insurance, and annual performance bonuses.
• Equal opportunity environment focused on belonging and support.