Nurse Investigator

United Trading Group; Salt Lake City (UT); Híbrido; USD 43.000 - 65.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Hybrid work

Full benefits package

Descripción de la vacante

The Utah Office of Inspector General of Medicaid Services (UOIG) seeks 2 experienced Registered Nurses to join its Program Integrity team as Nurse Investigators in Salt Lake City. You will review Medicaid services and use clinical judgment to support program integrity and detect improper care or overpayments.

Responsibilities include nursing record review, clinical utilization assessments, documentation of findings, and collaboration with clinicians and other stakeholders to advance Medicaid

Formación

• Current licensure as a Registered Nurse (RN) in Utah.
• Ability to review and interpret medical records independently.
• Strong clinical judgment and critical thinking for complex information.
• Ability to communicate findings clearly, both verbally and in writing.

Responsabilidades

• Review Medicaid medical records, claims, and documentation to evaluate medical necessity and level of care.
• Conduct clinical utilization reviews, including inpatient stays and related reviews.
• Evaluate patient condition support for billed services and apply Medicaid requirements.
• Document findings with rationale and evidence for case resolution.
• Collaborate with nurses, investigators, analysts, and other stakeholders as needed.
• Identify trends and potential fraud, waste, or abuse in reviews.

Conocimientos

Nursing judgment

Critical thinking

Clinical knowledge

Communication skills

Independent review

Educación

Utah RN license

Herramientas

InterQual criteria

Descripción del empleo

Nurse Investigator

The Utah Office of Inspector General of Medicaid Services (OIG) is seeking 2 experienced Registered Nurses to join its Program Integrity team. In this position, you will use your clinical knowledge, professional nursing judgment, and critical-thinking skills to review healthcare services provided to Medicaid members. You will independently evaluate clinical information and provide nursing expertise to support the OIG’s responsibility for protecting the integrity of the Medicaid program.

Job Details

FT / PT Status – Full-Time

Benefits Eligibility – This position is eligible for a full benefits package.

Salary – $31.54 - $47.34 Hourly Wage

Remote Work / In-Office – Hybrid

Key Responsibilities

As a Nurse Investigator, you job duties will include:

• Reviewing Medicaid medical records, claims, and supporting documentation to evaluate medical necessity, level of care, utilization, length of stay, and documentation supporting services billed to Medicaid.
• Conducting clinical utilization reviews, which may include one-day inpatient stays, readmissions, extended lengths of stay, outlier cases, inpatient rehabilitation, psychiatric inpatient services, and other targeted reviews.
• Evaluating whether the patient’s documented clinical condition supports the level of care and services billed.
• Applying professional nursing judgment, applicable Medicaid requirements, and nationally recognized clinical criteria, including InterQual when appropriate.
• Analyzing clinical documentation to identify unsupported or inappropriate services, potential overpayments, billing or utilization concerns, and potential indicators of fraud, waste, or abuse.
• Clearly documenting clinical findings, rationale, and supporting evidence and contribute to case findings, notices, and other written documentation.
• Providing clinical expertise during case reviews, provider discussions, reconsiderations, settlement conferences, and other case-resolution activities as needed.
• Identifying trends or recurring concerns involving utilization, documentation, level of care, billing, reimbursement, or quality of care that may warrant additional review.
• Maintaining accurate and timely case documentation and working knowledge of applicable Medicaid policies, provider manuals, clinical standards, and relevant state and federal healthcare requirements.
• Collaborating with nurses, investigators, auditors, analysts, managers, legal counsel, Medicaid program staff, healthcare providers, and other subject‑matter experts and assist with their projects on an as needed basis.
• Participating in other clinical reviews, audits, and program‑integrity activities based on emerging Medicaid risks and organizational priorities.

Qualifications

Minimum Qualifications:

• Current licensure as a Registered Nurse (RN) in the State of Utah.
• Clinical nursing knowledge and experience sufficient to independently review and interpret medical records and clinical documentation.
• Ability to exercise professional nursing judgment and apply critical thinking and reasoning when evaluating complex clinical information.
• Ability to read, analyze, and draw appropriate conclusions from medical records and other written information.
• Ability to clearly communicate clinical findings and supporting rationale, both verbally and in writing.
• Ability to work independently, organize and prioritize assignments, and meet established deadlines.
• Ability to appropriately handle confidential information and protected health information.
• Ability to successfully complete required background screening.

Preferred Qualifications:

• Experience in utilization review, utilization management, medical necessity review, clinical documentation review, healthcare auditing, or program integrity.
• Acute-care hospital nursing experience, including inpatient nursing, emergency services, critical care, case management, or a related clinical area.
• Experience conducting inpatient utilization or level-of-care reviews.
• Experience using InterQual, MCG, or another nationally recognized medical-necessity or level-of-care criteria set.
• Experience with Medicaid, Medicare, or another healthcare payer, including healthcare coverage, claims, reimbursement, utilization management, auditing, or compliance.
• Behavioral-health experience, including psychiatric inpatient services, substance-use-disorder services, behavioral-health utilization review, or other behavioral healthcare.
• Experience reviewing healthcare claims, medical records, billing documentation, coding, or reimbursement.

About the Role

Location –
288 North 1460 West
Salt Lake City, Utah, 84116
United States

Background Check Required – Yes

Drug Test Required – No

Schedule Code – B - Competitive Career Service

Why You Should Join Our Team

In Utah, we believe hard work is important, but balance is essential. Finding work/life balance is a vital element to our culture. To find out more about WHY Utah, click here. Other benefits may include:

• Job Stability: Enjoy the security and reliability of employment within a well-established organization.
• Career Growth: Develop valuable skills and gain opportunities for leadership within a large organization.
• Meaningful Work: Contribute to an important service that benefits the community and supports organizational goals.
• Supportive Work Environment: Be part of a team that values cooperation, strong work ethics, and mutual support.

The Agency

The Utah Office of Inspector General of Medicaid Services (UOIG) protects taxpayer dollars by identifying fraud, abuse and waste risks and vulnerabilities in the State Medicaid Program and by taking action to mitigate or eliminate those risks. You can find out more about The Utah Office of Inspector General of Medicaid Services by clicking here.

EEO Statement

The State of Utah is committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender identity, or Veteran status. We also consider qualified applicants regardless of criminal histories, consistent with legal requirements. For accommodations, please contact [phone].