Investigator, SIU RN-Remote

Lensa; City of Syracuse (NY); 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 detection of healthcare fraud. This role involves performing medical audits, conducting provider interviews, and generating detailed reports. Candidates should possess a strong clinical background and relevant experience in medical review and coding. The position offers a competitive salary and the opportunity to work in a dynamic environment focused on healthcare integrity.

Qualifications

• Five years clinical nursing experience with broad clinical knowledge.
• Five years experience conducting medical review and coding/billing audits.

Responsibilities

• Perform medical record audits to verify services and validate coding accuracy.
• Conduct interviews to determine potential fraud, waste, or abuse.
• Generate accurate written reports detailing audit findings.

Skills

Clinical Nursing

Medical Review

Coding

Billing

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 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

• 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.
• Conduct interviews of providers and/or health plan members to determine whether fraud, waste, or abuse may have occurred.
• Coordinate with various internal customers (e.g., Provider Services, Contracting and Credentialing, Healthcare Services, Member Services, Claims) to gather documentation pertinent to investigations.
• Detect potential health care fraud, waste, and abuse through the identification of aberrant coding and/or billing patterns through utilization review.
• Incorporate leadership and communication skills to work with physicians and other health professionals when investigating cases.
• Generate and provide accurate and timely written reports for internal and/external use detailing audit findings.
• Render provider education on appropriate practices (e.g., coding) as appropriate based on national or local guidelines, contractual, and/or regulatory requirements.
• 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 ensure continuity of care.
• Continuation of Services for Members
• Documentation of Transition of Services
• Transitions of Care Between Health Care 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 all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

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

Pay Range: $77,969 - $128,519 / ANNUAL

• Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Seniority level

• Mid-Senior level

Employment type

• Full-time

Job function

• Other, Information Technology, and Management

Industries

• IT Services and IT Consulting

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