Investigator, SIU RN-Remote

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

Job summary

A leading healthcare organization is seeking a Special Investigation Unit (SIU) Investigator to support fraud prevention and detection in healthcare. This role involves conducting audits, generating reports, and collaborating with various departments to maintain compliance and improve systems. The ideal candidate will have extensive nursing experience and knowledge of medical coding.

Benefits

Competitive benefits and compensation package

Qualifications

• Five years clinical nursing experience required.
• Two years managed care experience preferred.

Responsibilities

• Perform medical record audits to verify service documentation.
• Conduct interviews to determine fraud, waste, or abuse.
• Generate timely written reports detailing audit findings.

Skills

Clinical Nursing

Medical Review

Coding/Billing Audits

Medical Terminology

Education

Graduate from an Accredited School of Nursing

Bachelor’s Degree in Nursing

Job description

Be among the first 25 applicants and get AI-powered advice on this job and more exclusive features.

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 is responsible for reviewing and analyzing information to make medical determinations as necessary, and applies clinical knowledge to assess the medical necessity, level of services, and/or appropriateness of care in cases. The SIU Investigator is also responsible for recognizing and adhering to national and local coding and billing guidelines in order to maintain coding accuracy and excellence. The position also entails producing audit reports for internal and external review. The position may also work with other internal departments, including Compliance, Corporate Legal Counsel, and Medical Affairs, in order to achieve and maintain appropriate anti-fraud oversight.

Job Duties

1. Perform objective desk and onsite medical record audits to verify if services were supported by documentation, to determine if services were appropriately administered, and/or to validate coding/billing accuracy.
2. Conduct interviews of providers and/or health plan members to determine whether fraud, waste, or abuse may have occurred.
3. Coordinate with various internal customers (e.g., Provider Services, Contracting and Credentialing, Healthcare Services, Member Services, Claims) to gather documentation pertinent to investigations.
4. Detect potential health care fraud, waste, and abuse through the identification of aberrant coding and/or billing patterns through utilization review.
5. Incorporate leadership and communication skills to work with physicians and other health professionals when investigating cases.
6. Generate and provide accurate and timely written reports for internal and/external use detailing audit findings.
7. Render provider education on appropriate practices (e.g., coding) as appropriate based on national or local guidelines, contractual, and/or regulatory requirements.
8. Identify opportunities for improvement through the audit process and provide recommendations for system enhancement in order to augment investigative outcomes and performance.

Job Qualifications

REQUIRED EDUCATION: Graduate from an Accredited School of Nursing.

• REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES :
• Five years clinical nursing experience with broad clinical knowledge.
• Five years experience conducting medical review and coding/billing audits involving professional and facility based services.
• Knowledge and understanding of medical terminology along with demonstrated knowledge of CPT, ICD-9, HCPCS and DRG requirements.
• Two years of managed care experience.

Required License, Certification, Association: Active, unrestricted State Registered Nursing (RN) license in good standing.

Preferred Education: Bachelor’s Degree in Nursing

Preferred Experience:

• Experience in government programs (i.e., 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
• The Molina Transition of Care Coach will coordinate all services with new members to ensure a seamless transition and continuity of care.
• Continuation of Services for Members
• Documentation of Transition of Services
• Transitions of Care Between Healthcare Settings
• Transitions of Care Between Molina Healthcare of Ohio and the OhioRISE Plan
• Care Coordination Assignment
• Provision of Member Information
• Continuation of Services for Members
• Documentation of Transition of Services

To apply, current Molina employees should use the intranet job listing. Molina offers a competitive benefits and compensation package. We are an Equal Opportunity Employer (EOE) M/F/D/V.

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

Additional Details

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

Referrals increase your chances of interviewing at Lensa by 2x. Sign in to set job alerts for “Investigator” roles.