Investigative Clinician - Insurance Claims

@ CoventBridge Group

Overview

The Investigative Clinician - Insurance Claims is a remote role for licensed healthcare professionals (RN or NP) who are skilled in evaluating the medical validity of insurance claims. In this position, you will support a major national client by detecting and resolving fraudulent, exaggerated, or non-medically necessary claims.

Key Responsibilities

• Review medical records, treatment plans, and billing documentation.
• Identify patterns of overutilization, upcoding, and potential fraud.
• Provide clinical expertise to claims investigators, legal teams, and stakeholders.
• Interview claimants and healthcare providers to verify clinical details.
• Prepare detailed clinical summary reports.
• Deliver expert opinions on treatment appropriateness.
• Stay up-to-date with clinical practices, fraud trends, and billing guidelines.
• Participate in depositions or testify as a clinical expert if required.

Essentials for this Role

Candidates must hold an active U.S. license (RN, NP, MD, or equivalent), have 3–5 years of hands-on clinical experience, and preferably have prior experience in insurance claims review or healthcare fraud investigation. Proficiency with electronic health records (EHRs), ICD-10, CPT coding, and medical billing is required, along with strong analytical, communication, and report writing skills.

Preferred Qualifications

Preferred candidates will have certification in fraud investigation (e.g., CFE or AHFI), familiarity with claims management platforms, and a working knowledge of healthcare laws and insurance regulations.

Benefits and Compensation

• Career development training
• Medical, Dental, and Vision plans
• Life, LTD and STD coverage paid by the employer
• 401(k) with company match
• Paid vacation and parental leave
• Tuition assistance after one year

The salary range for this role is between $80,000 and $110,000 annually with adjustments based on qualifications and experience.

Equal Opportunity

CoventBridge Group is an equal opportunity employer committed to inclusion and providing reasonable accommodations for persons with disabilities. For any accommodation requests during the application process, please contact Human Resources at 888-932-7364 or humanresources@coventbridge.com.

Key skills/competency

• Insurance Claims
• Clinical Review
• Fraud Detection
• Analytical Skills
• EHR Proficiency
• Medical Billing
• Report Writing
• Interviewing
• Clinical Expertise
• Regulatory Knowledge