Investigator, SIU RN-Remote

Lensa; Atlanta (GA); Remote; USD 77,000 - 129,000; Full time

Job summary

An established industry player is seeking a dedicated SIU Investigator to combat healthcare fraud, waste, and abuse. This full-time role involves conducting thorough medical audits, collaborating with various departments, and applying clinical expertise to ensure compliance and integrity in healthcare practices. The ideal candidate will possess extensive nursing experience and a strong understanding of medical coding and billing. Join a dynamic team that values integrity and excellence, and contribute to meaningful improvements in healthcare oversight while enjoying competitive compensation and benefits.

Qualifications

• 5+ years of clinical nursing experience with broad clinical knowledge.
• Experience conducting medical review and coding/billing audits.

Responsibilities

• Perform medical record audits to verify documentation and coding accuracy.
• Conduct interviews to identify potential fraud, waste, or abuse.
• Generate and deliver timely audit reports detailing findings.

Skills

Clinical Nursing Experience

Medical Review Audits

Coding and Billing Knowledge

Managed Care Experience

Medical Terminology

Education

Graduate from an accredited School of Nursing

Bachelor’s Degree in Nursing

Job description

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Lensa is the leading career site for job seekers at every stage of their career. Our client, Molina Healthcare, is seeking professionals. Apply via Lensa today!

Job Description

Job Summary

The Special Investigation Unit (SIU) Investigator is responsible for supporting the prevention, detection, investigation, reporting, and when appropriate, recovery of money related to health care fraud, waste, and abuse. Duties include performing accurate and reliable medical review audits that may also include coding and billing reviews. The SIU Investigator reviews and analyzes information to make medical determinations, applying clinical knowledge to assess medical necessity, level of services, and appropriateness of care. The role also involves adhering to coding and billing guidelines, producing audit reports, and collaborating with internal departments such as Compliance, Legal, and Medical Affairs to maintain anti-fraud oversight.

Job Duties

1. Perform objective desk and onsite medical record audits to verify documentation support, appropriateness of services, and coding/billing accuracy.
2. Conduct interviews with providers and/or members to identify potential fraud, waste, or abuse.
3. Coordinate with internal teams to gather documentation pertinent to investigations.
4. Detect potential healthcare fraud, waste, and abuse through utilization review and identifying aberrant coding/billing patterns.
5. Work with physicians and health professionals during investigations.
6. Generate and deliver timely audit reports detailing findings.
7. Educate providers on proper practices based on guidelines and regulations.
8. Identify opportunities for improvement and recommend system enhancements to improve investigative outcomes.

Job Qualifications

Required Education: Graduate from an accredited School of Nursing.

• Five years of clinical nursing experience with broad clinical knowledge.
• Five years of experience conducting medical review and coding/billing audits for professional and facility-based services.
• Knowledge of medical terminology, CPT, ICD-9, HCPCS, and DRG requirements.
• Two years of managed care experience.

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

Preferred Education: Bachelor’s Degree in Nursing.

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

State-specific Requirements for Ohio

• Transitions of Care for New Members
• Provision of Member Information
• Pre-Enrollment Planning
• Continuation of Services for Members
• Documentation of Transition of Services
• Transitions of Care Between Settings and Plans

Interested employees should apply through the intranet. Molina Healthcare offers competitive benefits. This is a full-time, mid-senior level role in the fields of other, IT, and management, within the IT services and consulting industry. The pay range is $77,969 - $128,519 annually, with actual compensation varying based on location and experience.