Investigator, SIU RN-Remote

Lensa; Akron (OH); Remote; USD 77,000 - 129,000; Full time

Job summary

A leading healthcare organization is seeking a Special Investigation Unit (SIU) Investigator to support the prevention and investigation of healthcare fraud. The role involves conducting medical audits, coordinating with teams, and generating reports. Candidates must have a nursing background with significant experience in medical review and coding audits.

Benefits

Competitive benefits

Qualifications

• Minimum five years of clinical nursing experience.
• Five years of experience in medical review and coding/billing audits.
• At least two years of managed care experience.

Responsibilities

• Perform medical record audits to verify documentation support.
• Interview providers and members to identify potential fraud.
• Generate detailed audit reports for internal and external review.

Skills

Medical terminology

CPT

ICD-9

HCPCS

DRG requirements

Communication skills

Education

Graduate from an accredited School of Nursing

Bachelor’s Degree in Nursing

Job description

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Job Description

Job Summary

The Special Investigation Unit (SIU) Investigator supports the prevention, detection, investigation, reporting, and recovery of money related to healthcare fraud, waste, and abuse. Responsibilities include performing medical review audits, coding and billing reviews, analyzing information for medical determinations, and ensuring adherence to coding guidelines. The role involves producing audit reports and collaborating with internal departments such as Compliance, Legal, and Medical Affairs to maintain anti-fraud oversight.

Job Duties

• Perform medical record audits to verify documentation support, appropriateness of services, and billing accuracy.
• Interview providers and members to identify potential fraud, waste, or abuse.
• Coordinate with internal teams to gather investigation documentation.
• Identify aberrant coding and billing patterns to detect fraud and misuse.
• Work with healthcare professionals during investigations using strong communication skills.
• Generate detailed audit reports for internal and external review.
• Educate providers on proper coding and billing practices per guidelines.
• Suggest improvements based on audit findings to enhance investigation outcomes.

Job Qualifications

Required Education: Graduate from an accredited School of Nursing.

• Minimum five years of clinical nursing experience.
• Five years of experience in medical review and coding/billing audits.
• Knowledge of medical terminology, CPT, ICD-9, HCPCS, and DRG requirements.
• At least two years of managed care experience.

Required License: Active, unrestricted RN license in good standing.

Preferred Education: Bachelor’s Degree in Nursing.

Preferred Experience: Experience with government programs like Medicare, Medicaid, SCHIP, or in long-term care.

State-Specific Requirements for Ohio

• Transitions of Care for new members, including coordination and documentation.
• Ensuring continuity of care and proper service transition between providers and plans.

Interested Molina employees should apply via the intranet. Molina Healthcare offers competitive benefits. We are an Equal Opportunity Employer. Pay Range: $77,969 - $128,519 annually, depending on location, experience, education, and skills.

Additional Details

• Seniority level: Mid-Senior level
• Employment type: Full-time
• Job function: Other, IT, Management
• Industries: IT Services and Consulting

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