Nurse Investigator – Medicaid Program Integrity (Hybrid)

United Trading Group; Salt Lake City (UT); Hybrid; USD 43,000 - 65,000; Full time

Benefits offered by this job

Hybrid work

Full benefits package

Job summary

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

Qualifications

• 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.

Responsibilities

• 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.

Skills

Nursing judgment

Critical thinking

Clinical knowledge

Communication skills

Independent review

Education

Utah RN license

Tools

InterQual criteria

Job description

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