Investigator, SIU RN-Remote

Lensa; Dayton (OH); Remote; USD 77,000 - 129,000; Full time

Job summary

A leading healthcare company is seeking a Special Investigation Unit (SIU) Investigator to support fraud prevention and detection. The role involves conducting audits, analyzing medical necessity, and collaborating with various departments. Ideal candidates will have significant nursing experience and knowledge of coding guidelines. Competitive benefits and a full-time position are offered.

Benefits

Competitive benefits

Qualifications

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

Responsibilities

• Perform medical record audits to verify documentation support.
• Interview providers and members to identify potential fraud.
• Generate detailed audit reports for internal and external use.

Skills

Clinical Nursing

Medical Review Audits

Coding and Billing

Medical Terminology

Managed Care

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, and analyzing information to make medical determinations. The role involves assessing medical necessity, appropriateness of care, and maintaining coding accuracy according to guidelines. The SIU Investigator also produces audit reports and collaborates with internal departments such as Compliance, Legal, and Medical Affairs to ensure effective anti-fraud measures.

Job Duties

• Perform medical record audits to verify documentation support, appropriate service delivery, and coding accuracy.
• Interview providers and members to identify potential fraud, waste, or abuse.
• Coordinate with internal teams to gather documentation for investigations.
• Identify aberrant billing and coding patterns through utilization review.
• Work with healthcare professionals during investigations.
• Generate detailed audit reports for internal and external use.
• Educate providers on proper coding and billing practices based on guidelines.
• Recommend system improvements based on audit findings.

Job Qualifications

Required Education

Graduate from an accredited School of Nursing.

Experience/Skills

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

License and Certification

Active, unrestricted 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
• Care Coordination and Service Continuity

Interested employees should apply through the intranet. Molina offers competitive benefits. Equal Opportunity Employer. Pay Range: $77,969 - $128,519 annually. Actual pay may vary 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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