Investigator, SIU RN

• Perform 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, Healthcare 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 when investigating cases.

• Generate and provide accurate and timely written reports for internal and/external use detailing audit findings.

• Render 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 augment 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:

Bachelor’s Degree in Nursing

PREFERRED EXPERIENCE:

• Experience in government programs (i.e., Medicare, Medicaid, & SCHIP).
• Experience in long-term care.

STATE SPECIFIC REQUIREMENTS:

OHIO:

• Transitions of Care for New Members
• Molina Healthcare 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 all 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 (when applicable) and or collected by Molina (e.g. through assessments, new member outreach in advance of the member’s enrollment effective date) to identify existing sources of care and to ensure each new member is able to continue to receive existing services without disruption.
• For OhioRISE Plan enrolled members, Molina will reach 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 Molina Healthcare of Ohio and the OhioRISE Plan
• Care Coordination Assignment
• Provision of Member Information
• Continuation of Services for Members
• Documentation of Transition of Services

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Job Info

Job Identification: 2028625

Job Category: Legal, Risk, & Compliance

Posting Date: 2025-01-02T12:55:33 00:00

Job Schedule: Full time