Investigator, SIU RN-Remote

Lensa; Omaha (NE); 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, collaborating with internal teams, and generating detailed reports. Applicants should have significant nursing experience and an active RN license. Competitive benefits are offered.

Benefits

Competitive Benefits

Qualifications

• 5 years clinical nursing experience.
• 5 years conducting medical reviews and audits.
• 2 years managed care experience.

Responsibilities

• Perform medical record audits to verify documentation.
• Interview providers and members to investigate fraud.
• Generate audit reports detailing findings.

Skills

Medical Terminology

Coding Accuracy

Fraud Detection

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 recovery of money related to health care fraud, waste, and abuse. Duties include performing medical review audits, which may include coding and billing reviews. The SIU Investigator reviews and analyzes information to make medical determinations, assessing medical necessity, level of services, and appropriateness of care. The role requires adherence to coding and billing guidelines and producing audit reports. Collaboration with internal departments such as Compliance, Legal, and Medical Affairs is also part of the role.

Job Duties

• Perform medical record audits to verify documentation, appropriateness of services, and coding accuracy.
• Interview providers and members to investigate potential fraud, waste, or abuse.
• Coordinate with internal teams to gather investigation documentation.
• Identify fraud patterns through utilization review.
• Work with healthcare professionals during investigations.
• Generate audit reports detailing findings.
• Educate providers on coding and billing practices.
• Suggest improvements based on audit outcomes.

Job Qualifications

Required Education: Graduate from an Accredited School of Nursing.
Experience/Skills: 5 years clinical nursing experience, 5 years conducting medical reviews and audits, knowledge of medical terminology, CPT, ICD-9, HCPCS, DRG, and 2 years managed care experience.
License: Active RN license.
Preferred Education: Bachelor’s Degree in Nursing.
Preferred Experience: Experience with government programs and long-term care.

State Specific Requirements (Ohio)

• Transitions of Care for New Members
• Provision of Member Information
• Pre-Enrollment Planning
• Continuation of Services
• Documentation of Transitions

Applicants should apply through the intranet. Molina offers competitive benefits. Equal Opportunity Employer. Pay Range: $77,969 - $128,519 annually.

Additional Details

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

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