Clinical Investigator

Responsibilities: Identify and conduct clinical audits into suspected FWA with high autonomy Document findings, to include formal reports, graphs, audit logs, and other supporting documentation. Metrics to align with unit goals. Participate in the development and presentation of FWA-related education for Oscar teams Compliance with all applicable laws and regulations Other duties as assigned Requirements: Active, unrestricted Registered Nurse (RN) license 3+ years of direct patient care clinical experience. Case Management experience a bonus. 2+ years of experience in Medical Review, Utilization Management, or Clinical Documentation Improvement, featuring demonstrated expertise in the forensic application of complex clinical guidelines (e.g., MCG, CMS, and specialty-specific professional organizations) to multifaceted medical records. Experience conducting forensic medical audit with a focus on validating that clinical narrative supports the specificity and necessity of billed CPC, HCPCS, and ICD-10 codes. Bonus points: Bachelor of Science in Nursing (BSN), Associate Degree in Nursing (ADN) with a Bachelor of Science in Health Administration, Clinical Informatics, or a related Medical Science field, or Associate Degree in Nursing (ADN) with 5+ years of specialized clinical audit experience. Experience working in health insurance with competency regarding claims processing, billing, reimbursement, or provider contracting. Experience delivering feedback or education to providers/physicians in a professional, non-confrontational, and persuasive manner. Identifying trends, for example “cloned documentation” or change in billing habits of a provider. Experience with HIPAA, data privacy, and/or data security processes Certified Case Manager (CCM), Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or similar. This is an authentic Oscar Health job opportunity. Learn more about how you can safeguard yourself from recruitment fraud here . At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves and find both belonging and support. We're on a mission to change health care -- an experience made whole by our unique backgrounds and perspectives. Pay Transparency: Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education, and experience. Full-time employees are eligible for benefits including: medical, dental, and vision benefits, 11 paid holidays, paid sick time, paid parental leave, 401(k) plan participation, life and disability insurance, and paid wellness time and reimbursements. Artificial Intelligence (AI): Our AI Guidelines outline the acceptable use of artificial intelligence for candidates and detail how we use AI to support our recruiting efforts. Reasonable Accommodation: Oscar applicants are considered solely based on their qualifications, without regard to applicant’s disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team (accommodations@hioscar.com) to make the need for an accommodation known. California Residents: For information about our collection, use, and disclosure of applicants’ personal information as well as applicants’ rights over their personal information, please see our .