FWA CLINICAL INVESTIGATOR

The APWU Health Plan is seeking a FWA Clinical Investigator to join our Finance and Administration Division. This position audits clinical documentation and healthcare claims to identify billing irregularities, coding inaccuracies, and suspicious billing patterns. This role plays a critical part in strengthening the operation and cost-effectiveness of the health plan's FWA program by preventing improper payments and recovering lost revenue.

Primary Accountabilities

• Review electronic medical records (EMRs), clinical notes, itemized bills, and provider documentation to ensure validity, accuracy, and clinical justification of billed services.
• Analyze complex healthcare claims data to uncover suspicious provider billing behaviors, including upcoding, unbundling, duplicate billing, phantom billing, and overutilization.
• Draft evidence-based, detailed audit summaries, case briefs, and clinical rationales to support overpayment recoveries, provider corrective action plans, or referrals to OPM/OIG.
• Partner closely with investigators, data analysts, to build comprehensive evidence files for ongoing healthcare fraud investigations.
• Serve as the clinical subject matter expert for non-clinical investigators, translating complex medical workflows, documentation nuances, and provider notes into clear, actionable investigative leads.
• Other duties as assigned.

Qualifications

• An associate or bachelor’s degree in health information management, Nursing, Healthcare Administration, Medical Coding, Criminal Justice or related healthcare field.
• Five plus years if experience performing clinical documentation reviews.
• Must have experience with fraud, waste and abuse investigations, claims auditing of medical and behavioral health services and utilization review.

One of the following Certifications preferred

Certified Professional Coder (CPC)

Certified Coding Specialist (CCS)

Registered Health Information Technician (RHIT)

Registered Health Information Administrator (RHIA)

Certified Fraud Examiner (CFE)

Accredited Healthcare Fraud Investigator (AHFI)

Certified Professional Medical Auditor (CPMA)

• Demonstrated proficiency with Microsoft Office 365 including Excel, PowerPoint, Outlook, SharePoint and Word.
• Must have knowledge of federal and commercial insurance regulations as well as healthcare compliance requirements (HIPAA, OPM/OIG guidelines, CMS regulations).
• Experience with Electronic Medical Records (EMR/HER) system and claims processing systems as well as data analysis and reporting tools.
• Ability to define data and information needs; compile, analyze and interpret data relative to healthcare utilization.
• Ability to identify documentation inconsistencies and billing irregularities.
• Knowledge of medical terminology, CPT and ICD10 coding, investigative techniques, analytical methodologies, and insurance and claim operations.
• Highly organized, motivated self-starter with strong analytical, critical-thinking, attention to detail and problem solving skills.
• Excellent computer skills to include Microsoft Office, Healthcare Fraud Shield software suite, QNXT software suite, savvy internet research skills and Ad hoc query and reporting.
• Excellent analytical, verbal and written communication skills.