Investigator, SIU RN-Remote

Lensa; Bellevue (WA); Remote; USD 60,000 - 80,000; Full time

Job description

Be among the first 25 applicants.

Get AI-powered advice on this job and access 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 recovery of money related to health care fraud, waste, and abuse. Duties include performing accurate medical review audits, which may 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

• Perform objective desk and onsite medical record audits to verify documentation support, appropriateness of services, and billing accuracy.
• Conduct interviews with providers and members to investigate potential fraud, waste, or abuse.
• Coordinate with internal teams to gather documentation pertinent to investigations.
• Identify aberrant coding and billing patterns to detect fraud, waste, and abuse.
• Work with physicians and health professionals during investigations, demonstrating leadership and communication skills.
• Generate detailed audit reports for internal and external stakeholders.
• Educate providers on proper coding and billing practices according to guidelines and regulations.
• Recommend system improvements based on audit findings to enhance investigative outcomes.

Job Qualifications

Required Education: Graduate from an accredited School of Nursing.

• 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.
• 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 (Medicare, Medicaid, SCHIP) and 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

Current Molina employees interested in applying should do so through the intranet.

Molina Healthcare offers competitive benefits and compensation. We are an Equal Opportunity Employer (EOE) M/F/D/V.

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

Additional Details

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