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 fraud, waste, and abuse investigations within healthcare, utilizing clinical judgment and data analysis to develop investigative strategies. Proficient in regulatory submissions, corrective action recommendations, and maintaining accurate records in relevant databases.

Highest-signal resume keywords

Healthcare Fraud Investigation CertificationClinical Licensure in Massachusetts or New HampshireData Analysis and MiningInvestigative Report PreparationMicrosoft Office Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Fraud InvestigationMedical Record AuditsClaims AuditingUtilization ReviewData AggregationCPT CodingICD-10-CM CodingHCPCS CodingCorrective Action ManagementRegulatory Submission

Soft Skills

Strong Verbal CommunicationStrong Written CommunicationCritical ThinkingAttention to DetailCollaboration

Tools & Technologies

Case ShieldFWA DatabasesAnti-Fraud PlatformsMicrosoft Excel

Certifications & Qualifications

AHFICFEHCAFA

Industry Keywords

Healthcare Payer EnvironmentFraud ControlClinical NecessityProvider RelationsClaims Processing

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 accurate records in Case Shield and departmental FWA databases
Partner with Claims, Medical Management, Legal, and Provider Relations to implement corrective actions
Manage corrective action and repayment plans and 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
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 FWA vendors

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 disparate sources
Foundational understanding of CPT, ICD-10-CM, and HCPCS coding methodologies

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