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Senior Nurse Investigator

1 month ago

Baltimore, Maryland, United States CareFirst BlueCross BlueShield Full time
Job Summary

We are seeking a highly skilled Nurse Investigator to join our team at CareFirst BlueCross BlueShield. As a key member of our Special Investigations Unit, you will play a critical role in preventing, reducing, and recovering losses to our organization through clinical review of medical records and claims.

Key Responsibilities:

  • Conduct thorough reviews of medical records and claims to identify potential fraud and over-utilization
  • Investigate complex medical reviews of claims and medical records to determine the ability to pay or deny a claim
  • Provide detailed analysis and recommendations to support investigative teams
  • Maintain accurate records and documentation of findings
  • Collaborate with investigative teams to correlate review findings with appropriate actions

Requirements:

  • Bachelor's Degree in Nursing or equivalent experience
  • Active RN licensure in a Compact State
  • Coding certification (CPC or higher) preferred
  • 5 years of experience in nursing, with a focus on clinical review and investigation

What We Offer:

  • Competitive salary range: $65,736 - $130,559
  • Comprehensive benefits package
  • Opportunities for professional growth and development

About CareFirst BlueCross BlueShield:

We are an equal opportunity employer committed to diversity and inclusion. We offer a dynamic work environment and opportunities for professional growth and development.