Investigator, SIU RN-Remote

Lensa; Davenport (IA); Remote; USD 77,000 - 129,000; Full time

Job summary

A leading company is seeking a Special Investigation Unit (SIU) Investigator to support healthcare fraud prevention and investigation. The role involves conducting audits, analyzing billing patterns, and collaborating with various departments to ensure compliance. Candidates should have nursing experience and knowledge of coding guidelines.

Benefits

Competitive benefits package

Qualifications

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

Responsibilities

• Perform medical record audits to verify documentation and coding accuracy.
• Interview providers to identify potential fraud, waste, or abuse.
• Generate detailed audit reports.

Skills

Medical Terminology

Coding Accuracy

Fraud Detection

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 supports the prevention, detection, investigation, reporting, and recovery of money related to healthcare fraud, waste, and abuse. Responsibilities include conducting medical review audits, coding and billing reviews, analyzing information to make medical determinations, and ensuring adherence to coding and billing guidelines. The role involves producing audit reports and collaborating with internal departments such as Compliance, Legal, and Medical Affairs to maintain anti-fraud oversight.

Job Duties

• Perform medical record audits to verify documentation, appropriate services, and coding accuracy.
• Interview providers and members to identify potential fraud, waste, or abuse.
• Coordinate with internal teams to gather investigation documentation.
• Detect fraud through analysis of billing patterns.
• Work with healthcare professionals during investigations.
• Generate detailed audit reports.
• Educate providers on proper coding practices.
• Identify improvement opportunities and recommend system enhancements.

Job Qualifications

Required Education

Graduate from an accredited School of Nursing.

Required Experience, Skills & Abilities

• 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, Certification, and Association

Active, unrestricted State RN license.

Preferred Education

Bachelor’s Degree in Nursing.

Preferred Experience

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

Ohio State Specific Requirements

• Transitions of Care for New Members
• Provision of Member Information
• Pre-Enrollment Planning
• Documentation and Continuation of Services for Members
• Transitions between healthcare settings and with OhioRISE Plan

Interested employees should apply through the intranet.

Molina Healthcare offers a competitive benefits package and is an Equal Opportunity Employer. Pay Range: $77,969 - $128,519 annually, with actual compensation varying based on location, experience, education, and skills.

Additional Details

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

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