Clinical Investigator, MVP Health Care (Job ID: 1144)

Posted: 01/16/18 | SHARE:


MVP Health Care is a nationally-recognized, regional not-for-profit health plan.  We are committed to having a positive impact on the health and wellness of everyone and every community we serve. We care for more than 700,000 members across New York and Vermont, and we are powered by the ideas and energy of more than 1,600 employees – providing a wide range of health benefit plan options with attentive service and flexibility normally associated with a smaller company.  Stop settling for “just a job,” and join a company where you can reach your full potential…and make a positive difference!


The Clinical Investigator will investigate, review, and report on clinical aspects of cases identified as containing some element of fraud, waste, and/or abuse activity. In addition the Clinical Investigator will bring resolution to cases through restitution or education of involved parties. Utilize various data management tools to help identify potential fraudulent activity. Conduct clinical reviews of various forms of medical documentation and records obtained from providers and facilities including but not limited to medical charts, patient account records, and member interviews. Organize and conduct highly complex investigations. Document findings and recommendations throughout the investigative process in a timely and efficient manner according to corporate and departmental SIU policies and procedures. Act as an SIU liaison and interact with and analyze data in cooperation with Pharmacy, Medical Affairs, Operations, Provider Relations, Credentialing, Customer Care Center, Legal and other corporate personnel. Assist in investigations conducted by government agencies, law enforcement, and other insurance company SIU staff. Make recommendations for and conduct clinical re-audits of providers and facilities previously audited by SIU. Testify in criminal and civil legal case proceedings as necessary and assist outside legal counsel especially concerning issues needing clinical decision making. Participate in annual Corporate Fraud, Waste and Abuse training and training of new SIU personnel. Keep abreast of Federal and State anti-fraud investigation and reporting requirements including HIPAA, CMS, Medicare, Medicaid, and any corporate compliance initiatives or policies. Minimal travel may be required pertaining to investigations and audits. Ability to maintain confidentiality and adhere to regulatory compliance issues as they exist and change from time to time. Performs other related duties as assigned. 




Minimum Education:
New York State Registered Nurse license required.

BSN preferred. Maintain nursing license and coding credentials through continuing education process as required.

Obtain CPC certification within one (1) year of employment and/or COC credential.

Obtain Independent Adjuster License within two (2) years of employment.


Minimum Experience:
Minimum of 3-5 years clinical experience in an acute care setting.
Experience in health insurance fraud investigations preferred.


Required Skills:
•Working knowledge and the ability to efficiently operate relevant computer software including working knowledge of MS Office (Word, Excel and Outlook).

•Working knowledge of Macess, Facets, CareRadius, i-Sight, Cognos, STARSSentinel, CMS web sites, and/or Encoder-Pro strongly preferred.

•FWA data mining software experience preferred.

•Possess knowledge of CPT-4, ICD-9-CM, ICD-10-CM, HCPCS and CPT Assistant coding guidelines as they relate to claim data.

•Superior judgment skills, verbal and written communication, and presentation skills.

•Extremely detail-oriented with excellent organizational and analytical skills.

•Ability to travel throughout the MVP service area as needed. 


Additional Information:  

MVP Health Care is an Affirmative Action/Equal Opportunity Employer). We recruit, employ, train, compensate, and promote without regard to race, religion, creed, color, national origin, age, gender, sexual orientation, marital status, disability, genetic information, veteran status, or any other basis, e.g., Pay Transparency, protected by applicable federal, state or local law. Any person with a disability needing special accommodations to the application process, please contact Human Resources at

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