Investigator, SIU RN-Remote

Lensa; Madison (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. The role involves conducting audits, analyzing medical information, and collaborating with various departments. Ideal candidates will have extensive nursing experience and knowledge of coding standards. Competitive benefits are offered.

Qualifications

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

Responsibilities

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

Skills

Clinical Nursing

Medical Review

Coding Audits

Medical Terminology

CPT

ICD-9

HCPCS

DRG

Managed Care

Education

Graduate from an accredited School of Nursing

Bachelor’s Degree in 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 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 applying clinical knowledge to assess the necessity, level of services, and appropriateness of care, adhering to coding guidelines, and producing audit reports. Collaboration with other departments such as Compliance, Legal, and Medical Affairs is essential.

Job Duties

• Perform medical record audits to verify documentation support, appropriate services, and coding accuracy.
• Interview providers and members to identify potential fraud, waste, or abuse.
• Coordinate with internal teams to gather documentation for investigations.
• Detect fraud, waste, and abuse through billing pattern analysis.
• Work with healthcare professionals during investigations.
• Generate detailed audit reports.
• Educate providers on coding and billing practices.
• 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 conducting medical review and coding audits.
• Knowledge of medical terminology, CPT, ICD-9, HCPCS, and DRG.
• Two years managed care experience.

License and Certifications

Active, unrestricted RN license in good standing.

Preferred Education

Bachelor’s Degree in Nursing.

Preferred Experience

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

Ohio Specific Requirements

Includes transitions of care, documentation, and coordination for new members and continuity of services, as outlined in the provided details.

Interested employees should apply via the intranet. Molina Healthcare offers competitive benefits. Equal Opportunity Employer. Pay Range: $77,969 - $128,519 annually, varies by location and experience.

Additional Details

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