Investigator, SIU RN-Remote

Lensa; Bellevue (NE); 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 audits, analyzing medical information, and collaborating with various departments to ensure compliance and integrity in healthcare practices. Candidates should have significant nursing experience and a strong understanding of medical coding and billing.

Qualifications

• Five years of clinical nursing experience with broad clinical knowledge.
• Five years of experience conducting medical review and coding/billing audits.
• Active, unrestricted State Registered Nursing (RN) license in good standing.

Responsibilities

• Conduct objective desk and onsite medical record audits to verify documentation.
• Interview providers and members to identify potential fraud, waste, or abuse.
• Prepare detailed audit reports for internal and external review.

Skills

Clinical nursing experience

Medical review and coding/billing audits

Knowledge of medical terminology

Managed care experience

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 accurate medical review audits, coding, and billing reviews, analyzing information for medical determinations, and applying clinical knowledge to assess the necessity, level, 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

• Conduct objective desk and onsite medical record audits to verify documentation, appropriateness of services, and billing accuracy.
• Interview providers and members to identify potential fraud, waste, or abuse.
• Coordinate with internal teams to gather documentation for investigations.
• Identify aberrant coding and billing patterns to detect fraud, waste, and abuse.
• Collaborate with physicians and health professionals during investigations.
• Prepare detailed audit reports for internal and external review.
• Educate providers on proper practices based on guidelines and regulations.
• Identify opportunities for system improvements and recommend enhancements.

Job Qualifications

Required Education

Graduate from an accredited School of Nursing.

Required Experience/Skills

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

Required Licenses and Certifications

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

To apply, current Molina employees should use the intranet job listing. Molina offers competitive benefits. Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $77,969 - $128,519 per year. Actual compensation varies based on location, experience, education, and skills.

Additional Details

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