Investigator, SIU RN-Remote

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

Job summary

A leading healthcare provider is seeking a Special Investigation Unit (SIU) Investigator to support the prevention and detection of healthcare fraud. The role involves conducting medical audits, collaborating with internal teams, and generating reports. Ideal candidates will have extensive nursing experience and knowledge of coding and billing practices.

Qualifications

• Five years of clinical nursing experience with broad clinical knowledge.
• Five years of experience conducting medical reviews and audits.

Responsibilities

• Perform objective desk and onsite medical record audits.
• Conduct interviews with providers and/or members to investigate potential fraud.
• Generate detailed audit reports for internal and external review.

Skills

Clinical Knowledge

Leadership

Communication

Education

Bachelor’s Degree in Nursing

Graduate from an accredited School of Nursing

Job description

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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 as necessary, applying clinical knowledge to assess the medical necessity, level of services, and/or appropriateness of care. The role also involves recognizing and adhering to coding and billing guidelines to ensure accuracy, producing audit reports, and collaborating with internal departments like Compliance, Legal, and Medical Affairs to maintain anti-fraud oversight.

Job Duties

• Perform objective desk and onsite medical record audits to verify documentation support, appropriateness of services, and coding accuracy.
• Conduct interviews with providers and/or members to investigate potential fraud, waste, or abuse.
• Coordinate with internal teams to gather documentation for investigations.
• Detect fraud, waste, and abuse through analysis of coding and billing patterns.
• Work with healthcare professionals during investigations, demonstrating leadership and communication skills.
• Generate detailed audit reports for internal and external review.
• Provide provider education on coding and billing practices based on guidelines and regulations.
• Identify opportunities for process improvements and recommend system enhancements.

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 reviews and audits involving 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 Registered Nursing (RN) license in good standing.

Preferred Education: Bachelor’s Degree in Nursing.

Preferred Experience:

• Experience with government programs like Medicare, Medicaid, SCHIP.
• Experience in long-term care.

State-specific Requirements for Ohio

• Transitions of Care for New Members
• Provision of Member Information
• Pre-Enrollment Planning
• Continuation of Services and Documentation of Transitions
• Care Coordination and Member Outreach

Current Molina employees interested in applying should do so through the intranet. Molina offers competitive benefits. We are an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $77,969 - $128,519 / annually. Compensation may vary based on location, experience, education, and skills.

Seniority level

• Mid-Senior level

Employment type

• Full-time

Job function

• Other, Information Technology, Management

Industries

• IT Services and IT Consulting