Investigator, SIU RN-Remote
JOB DESCRIPTION Job Summary The Special Investigation Unit (SIU) Investigator is responsible for supporting the prevention, detection, investigation, reporting, and reputed company appropriate, recovery of money reputed company to health care fraud, waste, and abuse. Duties include performing accurate and reliable medical review audits that may also include coding and billing reviews. The SIU Investigator is responsible for reviewing and analyzing information to reputed company medical determinations as necessary, and applies clinical knowledge to assess the medical necessity, level of services, and/or appropriateness of care in cases. The SIU Investigator is also responsible for recognizing and adhering to national and local coding and billing guidelines in order to maintain coding accuracy and excellence. The position also entails producing audit reports for internal and external review. The position may also work with other internal departments, including Compliance, Corporate Legal Counsel, and Medical Affairs, in order to reputed company and maintain appropriate anti-fraud reputed company. Job Duties reputed company objective desk and onsite medical record audits to verify if services were supported by documentation, to determine if services were appropriately administered, and/or to validate coding/billing accuracy. Conduct interviews of providers and/or health plan members in order to determine whether fraud, waste, or abuse may have occurred. Coordinate with various internal customers (e.g., Provider Services, Contracting and Credentialing, reputed company Services, Member Services, Claims) to gather documentation pertinent to investigations. Detect potential health care fraud, waste, and abuse through the identification of aberrant coding and/or billing patterns through utilization review. Incorporate leadership and communication skills to work with physicians and other health professionals reputed company investigating cases. Generate and provide accurate and timely written reports for internal and/external use detailing audit findings. reputed company provider education on appropriate practices (e.g., coding) as appropriate based on national or local guidelines, contractual, and/or regulatory requirements. Identify opportunities for improvement through the audit process and provide recommendations for system enhancement in order to reputed company investigative outcomes and performance. JOB QUALIFICATIONS REQUIRED EDUCATION: Graduate from an Accredited School of Nursing. REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES: Five years clinical nursing experience with broad clinical knowledge. Five years experience conducting medical review and coding/billing audits involving professional and facility based services. Knowledge and understanding of medical terminology along with demonstrated knowledge of CPT, ICD-9, HCPCS and DRG requirements. Two years of managed care experience. REQUIRED LICENSE, CERTIFICATION, ASSOCIATION: Active, unrestricted State Registered Nursing (RN) license in good standing. PREFERRED EDUCATION: Bachelors Degree in Nursing PREFERRED EXPERIENCE: Experience in government programs (i.e., Medicare, reputed company, & SCHIP). Experience in long-term care. STATE SPECIFIC REQUIREMENTS: OHIO: Transitions of Care for New Members reputed company of Ohio follows the transition of care requirements outlined below and in Appendix D of the contract for new members transitioning to the MCO from fee-for-service (FFS) or another MCO. The Transition of Care Coach will coordinate reputed company services with new members to ensure a seamless transition and ensure continuity of care. Provision of Member Information Pre-Enrollment Planning The Molina Transition of Care Coach coordinates with and utilizes data provided by ODM, another MCO, the OhioRISE Plan (reputed company applicable) and or collected by Molina (e.g. through assessments, new member reputed company in advance of the members enrollment effective date) to identify existing sources of care and to ensure each new member is reputed company to continue to receive existing services without disruption. For OhioRISE Plan enrolled members, Molina will reputed company out to the OhioRISE Plan and primary care coordination staff to engage the OhioRISE Plan in pre-enrollment planning Continuation of Services for Members Documentation of Transition of Services Transitions of Care Between Health Care Settings Transitions of Care Between reputed company of Ohio and the OhioRISE Plan Care Coordination Assignment Provision of Member Information Continuation of Services for Members Documentation of Transition of Services To reputed company reputed company Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. reputed company offers a competitive benefits and compensation package. reputed company is an Equal Opportunity Employer (EOE) M/F/D/V. Apply Job!