Registered Nurse, Non-Institutional (Nurse Investigator) / 60018429, 61096625

Job Responsibilities

• Identifies fraud, waste, and abuse in the Medicaid Program by reviewing post paid claims.
• Conducts post-payment reviews of medical providers.
• Recovers excessive and inaccurate payments to providers and ensures compliance with Medicaid laws, regulations, and policies.
• Performs data analysis of post-paid claims.
• Develops case reviews, including conducting unannounced onsite visits, requesting medical records, sending provider/recipient survey letters, and making telephone calls to recipients to verify services.
• Coordinates and corresponds case actions with Managed Care Organizations (referring providers timely), Investigator, and other agencies such as UPIC, RAC, etc.
• Reviews all information received and compares it with Medicaid paid claims, applicable Medicaid rules, regulations, and policies, and all documentation or information obtained.
• Determines if fraud referrals are warranted and coordinates with supervisor to complete referrals to SC Medicaid Fraud Control Unit (SCMFCU) when fraud is suspected.
• Evaluates paid claims history data and determines patterns of practice and adherence to Medicaid program policy and procedures.
• Utilizes appropriate methodologies to conduct comparison studies, focus reviews, and random sampling, review universes of claims, self-audits, line-by-line samples, or random samples.
• Affirmatively evaluates the SURS algorithms used for payment analytics to determine their validity for recoupment from Managed Care Organizations (MCOs) and/or providers.
• Develops special reports in accordance with current health trends and practices using requisite nursing/dental/professional medical knowledge.
• Runs DCRs (detailed claims Excel report) and focused reports on paid claims data as needed in SAS.
• Researches and utilizes the current (BIS) Business Information Systems (SAS, MMIS etc.), SURS department, and Fraud Framework.
• Coordinates case actions with supervisor, program area staff, and investigator when indicated.
• Identifies and describes provider's aberrant billing patterns/billing errors within findings letters and on detailed claims reports, cites and/or includes policy validating errors, and makes provider recommendations to prevent improper billing in the future.
• Sets up AR (accounts receivable) when sending 30-day letters and tracks for appeals at 40-day mark.
• Maintains case progression monitoring at 15-day and 35-day intervals and responds to providers as necessary.
• Co-ordinates cases with MCOs, UPIC, RAC, and DQ when applicable.
• Drafts 30-day letters for UPIC and tracks for appeals before closing and setting up AR (Accounts Receivable).
• Coordinates informal conferences to discuss review findings when requested by providers and defends cases in fair hearings.
• Coordinates pre-hearing meetings with pertinent agency staff, including Office of General Counsel and program area representatives.
• Documents informal conferences or appeals processes.
• Co-ordinates informal meetings, pre-hearing conferences, and appeal hearings between State, UPICs, RACs, DQ, and MCOs.
• Refers providers to other agencies, Managed Care Organizations, or the relevant licensing board as deemed appropriate.

Minimum and Additional Requirements

• Graduation from an accredited school of nursing and two (2) years of clinical experience in a nursing setting.
• Necessary Special Requirement: Current licensure by the South Carolina State Board of Nursing as a Registered Nurse.
• Additional Requirements: Valid driver's license, sitting or standing for long periods, lifting 35 lbs., in-office role.

Preferred Qualifications

• Considerable knowledge of contemporary health care diagnosis and standard methods of treatment and therapy.
• Thorough knowledge of health care trends and practices; nursing expertise in order to conduct comprehensive reviews of medical services.
• Effective communication skills.
• Effective multitasking and prioritization skills within timeframes.
• Computer proficiency and knowledge of Microsoft Excel and Word.
• Ability to perform web-based software functions.
• Ability to work under limited supervision in conformance with established policies and procedures.
• Coordination of fraud cases with MCOs and the Attorney General's Office.

Benefits

• Health, Dental, Vision, Long Term Disability, and Life Insurance for Employee, Spouse, and Children.
• 15 days annual (vacation) leave per year.
• 15 days sick leave per year.
• 13 paid holidays.
• State Retirement Plan and Deferred Compensation Programs.