Nurse Investigator

About the role

The Nurse Investigator works as part of the Special Investigations Unit (SIU) team, detecting and investigating suspected fraud, waste, and abuse (FWA). This position conducts both pre-payment and post-payment reviews to ensure program integrity and supports fraud, waste, and abuse detection and investigation efforts. The role serves as the SIU’s subject matter expert in clinical reviews, coding, documentation, medical chart reviews, and billing audits.

Responsibilities

• Conduct full investigations, including data analysis, research, contract review, medical records review, interviews of patients/witnesses/providers, site visits, consulting with subject matter experts, coordination with law enforcement or regulatory agencies, and other investigative activities.
• Analyze and synthesize information from multiple sources (claims data, contracts, enrollment data, provider manuals, medical records, employee records, and state/federal regulations) to determine impact on claims payments related to SIU cases or leads.
• Create plans of investigation, determining scope, timing, and direction.
• Ensure investigations are completed lawfully, ethically, and appropriately.
• Document all investigative actions and decisions in the case management/tracking system.
• Execute investigative actions and decisions 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 to determine medical necessity, billing appropriateness, and sufficiency of documentation in evaluating potential fraud, waste, or abuse.
• Investigate, analyze, and render opinions on the delivery and billing of healthcare services.
• Conduct audits of medical charts and claims records.
• Utilize knowledge of healthcare coding, medical policies, and guidelines to assess claims submissions and make recommendations to the SIU, claims examiners, and stakeholders.
• Prepare findings identifying overpayments or inappropriate billing, documenting results in Word and overpayment calculations in spreadsheets.
• Prepare case reports for submission to regulatory and/or investigative agencies.
• Speak and act confidently when conveying information, including explaining overpayment determinations and providing court testimony.
• Coordinate with internal partners (Operations, Compliance, QI, Credentialing, Provider Delivery Services) to gather relevant information.
• Maintain licensure and certification, completing required continuing education.

Requirements

• Registered Nurse (RN).
• 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 Microsoft Office products, including Word and Excel.
• Critical problem-solving skills and attention to detail.

Qualifications (Preferred)

• Healthcare investigations, program integrity, or similar experience.
• 3+ years of 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.

Schedule

8:00 AM to 5:00 PM, 40 hours per week.