The SIU Clinical Nurse provides subject matter and clinical expertise to all investigators and analysts within the SIU, reviewing and analyzing medical records and medical coding and rendering and supporting professional recommendations in connection with SIU investigations. The SIU Clinical Nurse conducts medical investigations, especially those presenting complex issues of medical necessity. The SIU Clinical Nurse works with company medical director personnel and others to develop and advance anti-fraud, waste, and abuse initiatives.
- Analyzes medical records and medical coding in support of SIU medical investigations and works collaboratively with SIU personnel to advance all investigative work.
- Renders and substantiates professional recommendations on cases involving medical necessity, medical record documentation, and other clinical issues.
- Conducts investigations involving allegations of medical fraud or abuse by providers or members.
- Documents investigations and work in support of investigations for internal tracking and regulatory reporting purposes.
- Works with company medical directors and other company personnel on investigations and to develop and advance anti-fraud, waste, and abuse initiatives.
- Supports senior Compliance and Legal staff in all phases of investigation and litigation and testifies in court where necessary.
- Assists with providing training to SIU associates and other company colleagues.
- Performs special assignments as needed.
Education: High school diploma required; bachelor's degree or equivalent substantial work experience required.
Experience: At least five years of experience working as a registered nurse analyzing medical records and making medical necessity, authorization, or utilization decisions. Prior investigative experience or equivalent (legal services) preferred. Health insurance industry experience preferred. Knowledge of and experience working with government-funded health programs preferred.
Licenses/Certifications: Registered Nurse and Certified Professional Coder required. If candidate does not hold CPC credential, candidate will be required to obtain CPC credential within the first 12 months of employment.
Special Skills (e.g. 2nd language): Knowledge and understanding of claims processing systems, medical claims coding, and medical record documentation.
Technical Skills/Requirements: Basic personal computer skills necessary to navigate the MS-Windows operating system, Internet, health care claim systems, and other applications, is required. Ability to work effectively with Microsoft Office including Word, Excel, Outlook, Access, PowerPoint.