Investigator, SIU RN-Remote

Lensa; Nampa (ID); Remote; USD 77,000 - 129,000; Full time

Job summary

A leading healthcare firm is seeking a Special Investigation Unit Investigator to support the prevention and detection of healthcare fraud. The role involves auditing medical records, conducting interviews, and collaborating with various departments to maintain compliance. Ideal candidates will have a nursing background and experience in medical coding and billing audits. Competitive benefits and a full-time position are offered.

Qualifications

• Five years of clinical nursing experience.
• Two years of managed care experience.

Responsibilities

• Perform medical record audits to verify documentation and billing accuracy.
• Interview providers and members to identify potential fraud, waste, or abuse.
• Generate detailed audit reports for internal and external use.

Skills

Medical Terminology

Coding and Billing Audits

Fraud Detection

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 health care fraud, waste, and abuse. Responsibilities include performing medical review audits, coding and billing reviews, analyzing information for medical determinations, and ensuring adherence to coding and billing guidelines. The role involves producing audit reports and collaborating with departments like Compliance, Legal, and Medical Affairs to maintain anti-fraud measures.

Job Duties

1. Perform medical record audits to verify documentation and billing accuracy.
2. Interview providers and members to identify potential fraud, waste, or abuse.
3. Coordinate with internal departments to gather investigation documentation.
4. Identify aberrant billing patterns to detect fraud and abuse.
5. Work with healthcare professionals during investigations.
6. Generate detailed audit reports for internal and external use.
7. Educate providers on proper coding and practices.
8. Suggest improvements to enhance investigative outcomes.

Job Qualifications

Required Education: Graduate from an accredited School of Nursing.

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

Required License: Active, unrestricted State RN license.

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
• Continuation of Services and Documentation of Transitions
• Care Coordination and Member Service Continuity

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, and education.

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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