Investigator, SIU RN-Remote

Lensa; Warren (MI); Remote; USD 77,000 - 129,000; Full time

Job summary

A leading career site is assisting Molina Healthcare in recruiting a Special Investigation Unit Investigator. This role focuses on preventing and investigating healthcare fraud, requiring a nursing background and extensive experience in medical review audits. The investigator will collaborate with various departments to ensure compliance and improve investigation outcomes.

Qualifications

• Five years of clinical nursing experience required.
• Five years of experience in medical review and coding audits.
• Active RN license in good standing required.

Responsibilities

• Perform medical record audits and coding accuracy checks.
• Conduct interviews to identify potential fraud.
• Generate detailed audit reports for stakeholders.

Skills

Clinical nursing experience

Medical review audits

Knowledge of medical terminology

CPT, ICD-9, HCPCS, DRG requirements

Managed care experience

Education

Graduate from an accredited School of Nursing

Bachelor’s Degree in Nursing

Job description

Lensa, the leading career site for job seekers at every stage of their career, is assisting its client, Molina Healthcare, in recruiting professionals. Apply via Lensa today!

Job Description

Job Summary

The Special Investigation Unit (SIU) Investigator supports the prevention, detection, investigation, reporting, and recovery of funds related to healthcare fraud, waste, and abuse. Responsibilities include performing accurate medical review audits, coding and billing reviews, analyzing information to make medical determinations, and ensuring adherence to coding and billing guidelines. The role involves producing audit reports and collaborating with internal departments such as Compliance, Legal, and Medical Affairs to uphold anti-fraud measures.

Job Duties

1. Perform medical record audits to verify documentation, appropriateness of services, and coding accuracy.
2. Conduct interviews with providers and members to identify potential fraud, waste, or abuse.
3. Coordinate with internal teams to gather investigation documentation.
4. Identify aberrant coding or billing patterns indicating potential fraud or abuse.
5. Work with healthcare professionals during investigations, utilizing strong communication skills.
6. Generate detailed audit reports for internal and external stakeholders.
7. Educate providers on proper coding and practices according to guidelines and regulations.
8. Identify improvement opportunities and recommend system enhancements to improve investigative outcomes.

Job Qualifications

Required Education

Graduate from an accredited School of Nursing.

Required Experience, Skills & Abilities

• 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 services.
• Knowledge of medical terminology, CPT, ICD-9, HCPCS, and DRG requirements.
• Two years of managed care experience.

Required License & 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, SCHIP.
• Experience in long-term care settings.

State-specific Requirements for Ohio

• Transitions of Care for New Members, including coordination and documentation.

Current Molina employees should apply through the intranet. Molina offers competitive benefits. Equal Opportunity Employer. Pay Range: $77,969 - $128,519 annually, with actual compensation varying based on location, experience, and skills.

Additional Information

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