Investigator, SIU RN-Remote

Lensa; Kenosha (WI); 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 conducting audits, collaborating with various departments, and ensuring compliance with coding and billing guidelines. The ideal candidate will have extensive nursing experience and a strong understanding of medical terminology and coding practices. Join a dynamic team dedicated to maintaining integrity in healthcare services.

Benefits

Competitive benefits

Qualifications

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

Responsibilities

• Perform medical record audits to verify documentation and coding accuracy.
• Conduct interviews to determine potential fraud, waste, or abuse.
• Generate timely audit reports for internal and external use.

Skills

Clinical Nursing

Medical Review

Coding and Billing

Leadership

Communication

Education

Bachelor’s Degree in Nursing

Graduate from an accredited School of 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 other departments such as Compliance, Legal, and Medical Affairs to ensure anti-fraud measures.

Job Duties

1. Perform objective desk and onsite medical record audits to verify documentation support, appropriate service administration, and coding/billing accuracy.
2. Conduct interviews with providers and/or members to determine potential fraud, waste, or abuse.
3. Coordinate with internal teams to gather documentation relevant to investigations.
4. Detect potential healthcare fraud, waste, and abuse through analysis of coding and billing patterns.
5. Work with physicians and health professionals during investigations, demonstrating leadership and communication skills.
6. Generate timely and accurate audit reports for internal and external use.
7. Educate providers on proper coding and practices based on guidelines and regulations.
8. Identify opportunities for process improvements and provide recommendations to enhance investigative outcomes.

Job Qualifications

Required Education

Graduate from an accredited School of Nursing.

Required Experience/Skills

• Five years of clinical nursing experience with broad clinical knowledge.
• Five years of experience conducting medical review and coding/billing audits for professional and facility-based services.
• Knowledge of medical terminology, CPT, ICD-9, HCPCS, and DRG requirements.
• Two years of managed care experience.

Required License and Certification

Active, unrestricted State Registered Nursing (RN) license in good standing.

Preferred Education

Bachelor’s Degree in Nursing.

Preferred Experience

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

Ohio-Specific Requirements

• Transitions of Care for New Members
• Provision of Member Information
• Pre-Enrollment Planning
• Continuation of Services and Documentation of Transition
• Care Coordination and Transition between healthcare settings and plans

Interested employees should apply through the intranet. Molina offers competitive benefits 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 functions include: Other, IT, Management
• Industries: IT Services and Consulting