Investigator, SIU RN-Remote

Lensa; Jacksonville (FL); 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, waste, and abuse. The role involves conducting medical audits, collaborating with internal teams, and generating audit reports. Candidates should possess a nursing degree, clinical experience, and a valid RN license. This full-time position offers competitive benefits and a salary range of $77,969 - $128,519 annually.

Qualifications

• Five years clinical nursing experience required.
• Five years medical review and coding/billing audit experience required.
• Active, unrestricted RN license required.

Responsibilities

• Perform objective desk and onsite medical record audits.
• Conduct provider and/or member interviews to identify potential fraud.
• Generate detailed audit reports for internal and external use.

Skills

Clinical nursing experience

Medical review and coding/billing audit experience

Knowledge of medical terminology

CPT

ICD-9

HCPCS

DRG

Managed care experience

Education

Graduate from an Accredited School of Nursing

Bachelor’s Degree in Nursing

Job description

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Lensa is the leading career site for job seekers at every stage of their career. Our client, Molina Healthcare, is seeking professionals. Apply via Lensa today!

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 reviews and analyzes information to make medical determinations as necessary, applying clinical knowledge to assess the medical necessity, level of services, and appropriateness of care. The role also involves adhering to coding and billing guidelines, producing audit reports, and collaborating with internal departments to maintain anti-fraud oversight.

Job Duties

1. Perform objective desk and onsite medical record audits to verify documentation support, appropriateness of services, and coding/billing accuracy.
2. Conduct provider and/or member interviews to identify potential fraud, waste, or abuse.
3. Coordinate with internal teams to gather documentation pertinent to investigations.
4. Detect healthcare fraud, waste, and abuse through coding and billing pattern analysis.
5. Work with physicians and health professionals during investigations.
6. Generate detailed audit reports for internal and external use.
7. Educate providers on appropriate practices based on guidelines and regulations.
8. Identify improvement opportunities and recommend system enhancements.

Job Qualifications

Required Education: Graduate from an Accredited School of Nursing.

Experience/Skills: Five years clinical nursing experience, five years medical review and coding/billing audit experience, knowledge of medical terminology, CPT, ICD-9, HCPCS, DRG, and two years managed care experience.

License: Active, unrestricted RN license.

Preferred Education: Bachelor’s Degree in Nursing.

Preferred Experience: Experience in government programs and 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 Transition
• Transitions between healthcare settings and with OhioRISE Plan

Interested employees should apply through the intranet. Molina offers competitive benefits. Equal Opportunity Employer. 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, IT, Management
• Industries: IT Services and Consulting

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