This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description The Senior Analyst, SIU Clinical Investigator detects and audits aberrant billing patterns within claims and clinical documentation, using forensic clinical expertise to protect the integrity of healthcare spend. You will: - Perform comprehensive pre-payment and post-payment reviews of medical records to ensure billed services align with established clinical guidelines, CMS regulations, and contractual obligations. - Analyze provider behavior to identify schemes such as record cloning, upcoding, and unbundling that may be invisible to automated systems. - Act as a clinical subject matter expert to translate audit findings into relevant education. - Facilitate professional discussions with colleagues and providers to correct billing behaviors and promote long-term compliance. - Partner with clinical and non-clinical investigators to build evidentiary files for potential recovery, legal action, or referrals to appropriate outside agencies. You will report into the Investigations Manager, SIU. Qualifications - 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. Requirements - 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. Benefits - Employee benefits including medical, dental, and vision benefits. - 11 paid holidays. - Paid sick time. - Paid parental leave. - 401(k) plan participation. - Life and disability insurance. - Paid wellness time and reimbursements. - Participation in Oscar's unlimited vacation program. - Annual performance bonuses.

• Perform discovery visits to access sites for research partnerships. • Complete nomination, qualification, and site activation submissions, visits, and reports. • Ensure site compliance with protocol. • Ensure high quality data collection by attending patient enrollments, key time point follow-up visits, and monitoring visits as appropriate. • Provide protocol and product/procedural training to clinical sites. • Assist sites with pre-screening patients to ensure appropriateness for clinical study, as applicable. • Provide procedural support to ensure safety of subjects in clinical studies. • Help with registries, new technology assessments, and other special projects as needed.

• accountable for the strategic planning & management and performance of their assigned clinical trials from country allocation within feasibility process until study closure inclusive archiving at the CSU level • identify and anticipate risks jeopardizing the trial performance and develop and initiate countermeasures • working cross-countries or cross-clusters covering satellite countries • act on country/cluster level as the key strategic interface with internal and external stakeholders to develop, implement, maintain, and improve operational processes • represents the CTM perspective for CSU in organization wide initiatives • leads a study team through change management efforts and by example

• Develop and coordinate Phase 1 clinical research studies, ensuring all aspects of the study are meticulously planned and executed • Implement clinical research protocols and ensure compliance with regulatory requirements, including Good Clinical Practice (GCP) guidelines • Collaborate with principal investigators, research subjects, client teams, and clinic operations teams to facilitate smooth communication and coordination • Plan and manage logistics and resource usage for clinical trials, including scheduling, budgeting, and resource allocation • Track study progress and ensure alignment with project milestones, client deliverables, and budget, providing regular updates to stakeholders • Prepare and present study reports and updates to stakeholders, including detailed analysis of study data and progress • Ensure adherence to global and regional regulations and guidelines, staying up-to-date with any changes or updates • Provide guidance and support to lower-level professionals and team members, fostering a collaborative and supportive work environment • Identify and resolve any issues or challenges that arise during the course of the study, ensuring timely and effective solutions • Maintain accurate and comprehensive documentation of all study-related activities, ensuring transparency and accountability