Investigator, SIU RN-Remote

Lensa; Las Cruces (NM); Remote; USD 77,000 - 129,000; Full time

Job summary

A leading healthcare organization is seeking a Special Investigation Unit Investigator in Las Cruces, NM. This role involves investigating healthcare fraud, performing audits, and collaborating with various departments to ensure compliance. Candidates should have extensive nursing experience and be familiar with coding and billing practices. The position offers competitive benefits and a salary range of $77,969 - $128,519 annually.

Qualifications

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

Responsibilities

• Perform medical record audits to verify documentation and coding accuracy.
• Conduct interviews to determine potential fraud, waste, or abuse.
• Generate and deliver accurate audit reports detailing findings.

Skills

Clinical Nursing

Medical Review

Coding

Billing

Leadership

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 is responsible for reviewing and analyzing information to make medical determinations as necessary, and applies clinical knowledge to assess the medical necessity, level of services, and/or appropriateness of care in cases. The SIU Investigator is also responsible for recognizing and adhering to national and local coding and billing guidelines to maintain coding accuracy and excellence. The position also entails producing audit reports for internal and external review. The position may also work with other internal departments, including Compliance, Corporate Legal Counsel, and Medical Affairs, to achieve and maintain appropriate anti-fraud oversight.

Job Duties

• Perform objective desk and onsite medical record audits to verify if services were supported by documentation, determine if services were appropriately administered, and/or validate coding/billing accuracy.
• Conduct interviews of providers and/or health plan members to determine whether fraud, waste, or abuse may have occurred.
• Coordinate with internal teams (e.g., Provider Services, Contracting, Credentialing, Healthcare Services, Member Services, Claims) to gather documentation pertinent to investigations.
• Detect potential health care fraud, waste, and abuse through identification of aberrant coding and billing patterns via utilization review.
• Work collaboratively with physicians and health professionals during investigations, utilizing leadership and communication skills.
• Generate and deliver accurate, timely audit reports detailing findings for internal and external use.
• Provide provider education on appropriate practices, including coding, based on guidelines and regulations.
• Identify opportunities for process improvement and recommend system enhancements to improve investigative outcomes and performance.

Job Qualifications

Required Education: Graduate from an Accredited School of Nursing.

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

Required License, Certification, and Association: Active, unrestricted State Registered Nursing (RN) license in good standing.

Preferred Education: Bachelor's Degree in Nursing

Preferred Experience:

• Experience with government programs (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
• Documentation and Coordination of Services during transitions

All interested Molina employees should apply through the intranet.

Molina Healthcare offers competitive benefits and compensation. We are an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $77,969 - $128,519 / annual

• 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 IT Consulting

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