Clinical Healthcare Fraud Investigator - Nurse… at Allied… · Chester

Overview

Company Overview:

Advance Your Career in Insurance Claims with Allied Universal® Compliance and Investigation Services. Allied Universal® Compliance and Investigation Services is the premier destination for a career in insurance claim investigation. As a global leader, we provide dynamic opportunities for claim investigators, SIU investigators, and surveillance investigators. Our team is committed to innovation and excellence, making a significant impact in the insurance industry. If you’re ready to grow with the best, explore a career with us and make a difference.

Job Description

Allied Universal® is hiring a Clinical Healthcare Fraud Investigator - Nurse Auditor. The Nurse Auditor within the Special Investigations Unit (SIU) is responsible for conducting complex clinical and coding audits to identify potential fraud, waste, and abuse (FWA) across healthcare claims. This exempt-level position requires advanced clinical judgment, specialized auditing and coding expertise, and independent evaluation of medical records, provider documentation, and claim submissions. The Nurse Auditor applies professional nursing knowledge, CPT/HCPCS and ICD coding principles, and federal/state regulatory standards to support investigative activities and ensure program integrity. Some travel may be required for professional investigative activities, interviews, or continuing education.

RESPONSIBILITIES:

• Perform in‑depth medical record and claim audits using professional nursing expertise and advanced coding principles (CPC, CPMA, or equivalent)
• Analyze medical necessity, documentation sufficiency, coding accuracy, and adherence to clinical and regulatory guidelines
• Support SIU investigations by preparing clinical audit summaries, findings, and recommendations
• Develop and present clinical and coding-related expert insights to internal stakeholders, legal counsel, and external regulatory partners
• Collaborate with investigators, data analysts, and compliance personnel to identify trends indicative of fraud, waste, or abuse
• Provide clinical subject matter expertise on suspected aberrant billing patterns, high-risk providers, or questionable service delivery models
• Review clinical data, utilization patterns, and service claims for appropriateness and compliance
• Assist in the development of audit methodologies, investigative strategies, and provider education
• Participate in case conferences, interviews, and investigative planning sessions
• Ensure all audit activities conform to federal/state regulations, CMS guidance, industry standards, and organizational policies

QUALIFICATIONS (MUST HAVE):

• Active Registered Nurse (RN) license
• Coding or auditing certification such as Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), Certified Fraud Examiner (CFE), or equivalent
• Minimum of three (3) years of clinical experience in acute, outpatient, or specialty care settings
• Experience in medical record auditing, clinical claims review, or healthcare fraud investigation
• Experience applying federal and state healthcare regulations in complex audit environments
• Professional experience in performing high-level analytical research and evaluative skills
• Advanced knowledge of CPT, HCPCS, ICD-10-CM/PCS Coding Systems, healthcare fraud, waste and abuse indicators
• Strong working knowledge of CMS and commercial payer coverage rules as well as medical necessity and clinical documentation standards
• Proficiency in the use of Microsoft Office Suite applications
• Ability to maintain a high level of productivity with strong attention to detail and organizational skills
• Strong oral and written interpersonal communication skills
• Strong analytical, critical-thinking, and technical written communication skills
• Ability to exercise discretion and independent judgment in matters of significance

PREFERRED QUALIFICATIONS (NICE TO HAVE):

• Demonstrated working knowledge of Managed Care and the Medicaid and Medicare programs
• Professional certifications demonstrating specialized expertise, such as Certified Fraud Examiner (CFE), Certified in Healthcare Compliance (CHC), Certified Internal Auditor (CIA), Accredited Healthcare Fraud Investigator (AHFI) or healthcare coding certifications (CPC, CPMA, etc.)

BENEFITS:

• Medical, dental, vision, basic life, AD&D, retirement plan and disability insurance
• Seven paid holidays annually, sick days available where required by law
• Vacation time offered at an initial accrual rate of 3.08 hours biweekly; unused vacation is only paid out where required by law

Closing

Allied Universal® is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race/ethnicity, age, color, religion, sex, sexual orientation, gender identity, national origin, genetic information, disability, protected veteran status or relationship/association with a protected veteran, or any other basis or characteristic protected by law. For more information: www.aus.com

If you have difficulty using the online system and require an alternate method to apply or require an accommodation, please contact our local Human Resources department. To find an office near you, please visit: www.aus.com/offices.

Requisition ID

2026-1594868