Clinical Investigator

AP Professionals of WNY
July 19, 2022
Job Type


I. Overview
The Clinical Investigator will be responsible for medical record and coding reviews on cases
involving suspected fraudulent or abusive activity. These reviews will entail researching standards
of care, reviewing medical record documentation, and reviewing other documentation, in accordance
with industry clinical coding standards, Company policies, and the Company
Fraud Prevention Plan.

II. Qualifications
A. LPN or RN required.
B. Four (4) years of clinical experience required with medical insurance claims and medical
record reviews/audits using standard coding (HCPC, CPT, ICD-9, ICD-10, and)
preferred; experience in a managed care setting preferred.
C. Certification of CPC (Certified Professional Coder) is required at hire or within 12
months of being hired into the role.
D. Familiarity and experience with insurance investigative processes, provider licensure and
quality of care issues preferred.
E. Works independently with a wide latitude of freedom to determine the direction of cases.
F. Ability to assume responsibility, maintain data and reports in consideration of and
maximization of confidentiality.
G. PC/Windows experience and knowledge of claims audit software preferred.
H. Demonstrated ability to prepare medical record audit reports.
I. Strong organizational skills, verbal and written communication skills.
J. Demonstrated ability to communicate with providers, and efficiently and accurately
gather information from provider offices.
K. Proven examples of displaying these values: Passionate, Caring, Respectful,
Trustworthy, Collaborative, and Accountable.

III. Essential Accountabilities
A. Assist in identifying potential fraud and gathering the documentation needed to conduct
an investigation in accordance with Company’s Fraud Prevention Plan.
o Identify medical record issues that provide evidence for cases.
o Research standards of care pertaining to the medical issues identified in the cases.
and assess and evaluate documentation and coding evident on claim audits.
o Review medical record documentation provided in each case and identify the
appropriate course of action.
o Collect, analyze and interpret the clinical data.
o Summarize the clinical findings and provide direction/disposition of the cases.
o Assist in the identification, detection, and prevention of fraudulent/abusive
o Review output from computerized fraud system and make determination to pay or
deny claims.
B. Organize and manage reports/data
o Control and maintain reports, data and documentation of clinical findings for an
investigation in an organized manner.
o Identify areas of opportunity for company policies /procedures as identified
during analysis.
C. SIU/LGL Support
o Assist the SIU Director and the supporting legal counsel with SIU issues.

IV. Working Conditions & Physical Demands
• Work is typically performed in an office environment with some physical demands such
as: sitting for long periods of time (6-8 hours per day) bending, stretching, lifting, typing,
speaking, hearing, handling, fingering, lifting up to 5 lbs., near acuity/clarity with or
without correction, subject to inside environmental conditions but not necessarily from
temperature changes, subject to moderate noise, and normal exposure to everyday risks
and discomfort requiring common safety precautions.
• While performing the duties of this job, the associate is regularly required to
communicate professionally in person, over the telephone, through email and other
electronic means, handle various types of media and equipment, and visually or otherwise
identify, observe and assess. Responsibilities occasionally may require an adjusted work
schedule and evening hours in order to meet deadlines.
• The work environment characteristics described above are representative of those an
associate encounters while performing the essential functions of this job. Reasonable
accommodations may be made to enable qualified individuals with disabilities to perform
the essential functions.
• The ability to telecommute (work remotely off-campus) as required on a regular basis or
whenever necessary to continue business operations.
• Maintains confidentiality and uses only the minimum amount of protected health
information (PHI) necessary to accomplish job related responsibilities.
• Other duties as needed. Every associate is given a job description upon hire outlining the
qualifications, duties, and pay grade of the position. The Company reserves the
right to change job descriptions as necessary.
• Will adhere to all federal and state laws, rules and regulations, and Company
policies and procedures. Promote a professional and ethical environment through active
engagement with the Company's Compliance Program.

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