About This Role
Our client is seeking an experienced SIU Clinical Investigator / Healthcare Compliance Professional to support a growing Special Investigations Unit (SIU). This role focuses on conducting clinical and compliance reviews of medical records to identify potential fraud, waste, abuse, and billing irregularities. The individual will not maintain a traditional investigation caseload but will serve as a subject matter expert, performing detailed reviews and analyses of complex healthcare claims and documentation.
What You Will Work On
- Review medical records, claims, and supporting documentation for clinical consistency, completeness, and compliance.
- Identify potential indicators of fraud, waste, and abuse, including:
- Cloning of medical documentation
- Upcoding
- Billing inconsistencies
- Unsupported services and procedures
- Medical necessity concerns
- Conduct initial reviews and assessments of complex healthcare cases to determine potential compliance risks.
- Analyze documentation to validate medical necessity and appropriateness of billed services.
- Collaborate with SIU investigators and leadership to support ongoing investigations.
- Document findings and provide clear recommendations for further review or action.
- Stay informed of healthcare regulations, billing guidelines, and industry best practices.
What You Will Bring
- Experience in healthcare investigations, healthcare compliance, SIU, clinical auditing, utilization review, medical record review, or related healthcare oversight functions.
- Strong understanding of medical necessity criteria and healthcare documentation standards.
- Knowledge of healthcare fraud schemes, billing practices, and claims review methodologies.
- Experience reviewing complex medical records and identifying documentation discrepancies.
- Ability to analyze clinical information and communicate findings effectively.
- Clinical background strongly preferred.
- Experience in healthcare payer, managed care, SIU, fraud investigations, clinical auditing, or healthcare compliance environments is highly desirable.
What You Can Expect
- An inspirational place for you to do your best work, be engaged in meaningful ways, and continually develop the skills, competencies and qualities that set our team apart.
- Compensation commensurate with your qualifications, experience, and other factors including geographic location, market and operational factors.
- Total Rewards include: Medical, Dental, Vision, Life Insurance, Disability Insurance, 401(k) Savings Plan, Employee Stock Purchase Plan, Professional Development Program, Paid Time Off and Paid Sick Time (in geographies where legally required).
What We Do
At RGP, we're creating a future where businesses produce their best work without constraints. We've built a global network of over 2,600 experts across four regions, providing a comprehensive suite of solutions across on-demand talent, next-generation consulting, and outsourced services to support organizations at every stage of their growth journey. Trusted by Fortune 100 companies and emerging disruptors alike, we challenge conventional ways of working, drive growth, and pave the way for long-term success through bold innovation and fearless collaboration.
Our values guide everything we do and strengthen our commitment to people. By combining smart processes, human-centered design, and advanced technology, we celebrate our team's excellence and ensure we grow together. We believe in the power of continuous learning and development to drive both individual and organizational success. It’s time to rethink how work gets done. Dare to Work Differently® with RGP.
RGP is proud to be an Equal Opportunity Employer and committed to creating an inclusive environment for all employees. We do not discriminate on the basis of race, color, religion, national origin, gender, pregnancy, sexual orientation, gender identity, age, physical or mental disability, genetic information, veteran status, or any other legally protected trait and encourage all applicants to apply.
