Clinical Investigator II

Boston Medical Center (BMC)

. Lead clinically complex fraud, waste, and abuse investigations, including medical record audits and provider/member interviews .

Posted 10/30/2026full-timeRemote • United StatesMid-LevelSenior💰 $78,000 - $113,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in leading complex fraud investigations within healthcare, utilizing clinical judgment and data analysis to identify fraud, waste, and abuse. Proficient in regulatory submissions, investigative reporting, and collaboration with various stakeholders in the healthcare payer environment.

Highest-signal resume keywords

Healthcare Fraud Investigation CertificationClinical Licensure in Massachusetts or New HampshireData Analysis and MiningInvestigative Reporting and DocumentationProficiency in Microsoft Office, Especially Excel

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Fraud InvestigationData AnalysisClaims AuditingMedical Record ReviewCPT CodingICD-10-CM CodingHCPCS CodingInvestigative Strategy DevelopmentPayment Suspension ProcessesOverpayment Recovery

Soft Skills

Strong Verbal CommunicationStrong Written CommunicationAttention to DetailCritical ThinkingCollaboration

Tools & Technologies

Case ShieldFWA DatabasesAnti-Fraud PlatformsExcel Pivot TablesFacets Claims Processing

Certifications & Qualifications

AHFICFEHCAFAHealthcare Coding CertificationCPCCCSCCS-P

Industry Keywords

Healthcare Payer EnvironmentManaged CareMedicaid Fraud DetectionBehavioral HealthRegulatory Submissions

About the role

Key responsibilities & impact

Lead clinically complex fraud, waste, and abuse investigations, including medical record audits and provider/member interviews
Prepare investigative reports, corrective action recommendations, agency referrals, and regulatory submissions
Maintain timely records in Case Shield and departmental FWA databases
Partner with Claims, Medical Management, Legal, and Provider Relations on corrective actions, payment suspension, overpayment recovery, and repayment plans
Process claims in SIU pend queues
Serve as the SIU clinical resource on medical necessity, coverage policies, and documentation
Triage referrals and allegations using clinical judgment, claims, and prescribing data
Conduct data mining and analyze anti-fraud platform intelligence to identify FWA and refine clinical detection algorithms
Support law enforcement investigations and prosecutions, including testimony
Serve as a point of contact with New Hampshire and/or Massachusetts state agencies and liaise with vendor FWA activities
Keep the SIU Director informed of regulatory, vendor, and investigative developments

Requirements

What you’ll need

Bachelor's degree in nursing and five years of experience in a healthcare payer environment, healthcare fraud control, or a comparable investigative role, case management, utilization review, or claims auditing; or equivalent combination of education and experience
Clinical licensure in Massachusetts or New Hampshire (e.g. APRN, RPh, LICSW, LMHC, PharmD, RN)
Professional certification in healthcare fraud investigation or examination, including AHFI, CFE, or HCAFA, required within 12 months of start date
Proficiency with Microsoft Office, including Excel pivot tables
Ability to develop investigative strategies for complex, clinically sensitive fraud cases
Strong verbal and written communication skills
Ability to review, proofread, and edit investigative reports and regulatory submissions
Ability to aggregate, triangulate, and evaluate data from clinical records, claims history, and provider billing patterns
Foundational understanding of CPT, ICD-10-CM, and HCPCS coding methodologies
Advanced degree in Nursing or related clinical discipline preferred
Experience in managed care, Medicaid Managed Care, Medicaid fraud detection, behavioral health, Facets claims processing, external auditing, medical record review, or claims processing preferred
Healthcare coding certification such as CPC, CCS, or CCS-P preferred

Benefits

Comp & perks

Medical, dental, vision, and pharmacy benefits
Discretionary annual bonuses
Merit increases
Flexible Spending Accounts
403(b) savings matches
Paid time off
Career advancement opportunities
Resources to support employee and family well-being