Nurse Investigator

The Health Plan (THP); Wheeling (WV); On-site; USD 65,000 - 90,000; Full time

Job summary

The Health Plan (THP) seeks a Nurse Investigator to join the Special Investigations Unit in Wheeling, WV. The role conducts pre-payment and post-payment reviews, medical chart reviews, and supports fraud, waste, and abuse detection efforts.

Responsibilities include data analysis across claims, documentation in case management systems, and coordination with Operations, Compliance, and regulators. RN licensure and coding certification are required, with proficiency in ICD-9/10, CPT, HCPCS, DRG/Rev

Qualifications

• RN licensure required.
• Certified Coder or eligible within 12 months.
• Basic knowledge of ICD-9/10, CPT, HCPCS, DRG and/or Rev codes.
• Proficiency with Word and Excel.
• Strong problem-solving and attention to detail.

Responsibilities

• Conduct pre-payment and post-payment reviews and investigations.
• Analyze claims, contracts, enrollment data, and docs to assess medical necessity and potential fraud/waste/abuse.
• Document actions and findings in the case management system and prepare case reports.

Skills

Critical problem-solving

Attention to detail

Education

Registered Nurse license

Certified Coder (or eligible within 12 months)

Tools

Word

Excel

Job description

The Nurse Investigator works as part of the Special Investigations Unit (SIU) team, detecting and investigating suspected fraud, waste, and abuse (FWA). This position is responsible for conducting both pre-payment and post-payment reviews to ensure program integrity, and to support fraud, waste, and abuse detection and investigation efforts. This position serves as the SIU’s subject matter expert in terms of clinical reviews, coding and documentation, conducting medical chart reviews and billing audits. The successful candidate will utilize their unique blend of coding, claims payment, clinical, and payment integrity/investigations expertise to assist the SIU in achieving its mission to prevent, detect, investigate, and resolve healthcare fraud, waste, and abuse.

Required

• Registered Nurse;
• Certified Coder (or eligible within 12 months) or similar certification;
• Basic knowledge of ICD-9/10, CPT, HCPCS, DRG and/or Rev codes;
• Proficiency with Office products, including Word and Excel;
• Critical problem-solving skills and attention to detail.

Desired

• Healthcare investigations, program integrity, or similar experience;
• 3 years Medical Claims or multi-discipline clinical experience;
• Regulatory experience relevant to healthcare;
• Experience with WV Medicaid, Medicare Advantage, and/or Fully-Funded Commercial Health Insurance;
• Familiarity with CMS regulations.

Responsibilities

• Conducting full investigations which may include data analysis, research, contract review, medical records review, interviews of patients/witnesses/providers, site visits, consulting with other subject matter experts, coordination with law enforcement or regulatory agencies, and other necessary investigative activities;
• Analyzing and synthesizing information from multiple sources including claims data, contracts, enrollment data, provider manuals, educational materials, bulletins, medical records, employee records, and state and federal regulations, to determine impact on claims payments as it relates to SIU cases or leads;
• Creating plans of investigation, determining scope, timing, and direction of investigation;
• Ensuring investigations are completed in a lawful, ethical, and appropriate manner;
• Properly documenting all investigative actions and decisions in the case management/tracking system;
• Ensuring all investigative actions and decisions are executed expeditiously, with integrity and discretion;
• Serve as a subject matter expert for medical reviews, coding, and documentation;
• Review and analyze healthcare claims, medical records, physician statements, care management reports, and other documentation which requires interpretation and understanding of state and federal regulations, standards of care, applicable benefit language, and reimbursement language to determine medical necessity, billing appropriateness, and sufficiency of documentation in the evaluation of cases for potential fraud, waste, or abuse;
• Investigate, analyze, and render opinions on the delivery and billing of health care services
• Conduct audits of medical charts and claims records;
• Utilize knowledge of healthcare coding, medical policies, and other relevant guidelines to assess claims submissions and make appropriate recommendations to the SIU, claims examiners, and other relevant stakeholders;
• Prepare findings identifying overpayments and/or inappropriate billing, documenting findings in a Word document, and overpayment calculations in a spreadsheet;
• Prepare case reports for submission to regulatory and/or investigative agencies;
• Speak and act confidently when conveying information, including explaining overpayment determinations which may include court testimony;
• Coordinate with internal partners including Operations, Compliance, QI, Credentialing, and Provider Delivery Services to gather information relevant to the investigation;
• Maintain licensure and certification, completing required continuing education.

8:00am to 5:00pm

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