Investigator, SIU RN-Remote

Lensa; Dallas (TX); Remote; USD 77,000 - 129,000; Full time

Job summary

A leading healthcare company is seeking a Special Investigation Unit (SIU) Investigator to support the detection and investigation of healthcare fraud. The role involves conducting audits, generating reports, and collaborating with internal departments. Candidates should have a strong clinical background and experience in medical review and coding audits.

Qualifications

• Five years of clinical nursing experience.
• Five years of experience conducting medical review and coding/billing audits.

Responsibilities

• Perform objective medical record audits to verify documentation and coding accuracy.
• Conduct interviews with providers to investigate potential fraud.
• Generate audit reports detailing findings.

Skills

Medical Terminology

Coding Accuracy

Clinical Knowledge

Fraud Detection

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 is responsible for supporting the prevention, detection, investigation, reporting, and recovery of money related to health care fraud, waste, and abuse. Duties include performing medical review audits, including coding and billing reviews, and analyzing information to make medical determinations. The SIU Investigator applies clinical knowledge to assess the necessity, level of services, and appropriateness of care, adhering to coding and billing guidelines. The role also involves producing audit reports and collaborating with internal departments to maintain anti-fraud oversight.

Job Duties

• Perform objective medical record audits to verify documentation, appropriateness of services, and coding accuracy.
• Conduct interviews with providers and members to investigate potential fraud, waste, or abuse.
• Coordinate with internal departments to gather documentation pertinent to investigations.
• Identify aberrant coding and billing patterns to detect fraud, waste, and abuse.
• Work with healthcare professionals during investigations.
• Generate audit reports detailing findings.
• Educate providers on proper coding and practices according to guidelines.
• 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.
• 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 License: Active, unrestricted State Registered Nursing (RN) license.

Preferred Education

Bachelor’s Degree in Nursing.

Preferred Experience

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

Ohio-specific Requirements

• Transitions of Care for New Members
• Provision of Member Information
• Pre-Enrollment Planning
• Documentation and coordination related to transitions of care and services.

Interested Molina employees should apply through the intranet. Molina offers competitive benefits. Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $77,969 - $128,519 / annually. Actual compensation varies 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 Consulting