Nurse Investigator

As a Nurse Investigator, you job duties will include: Reviewing Medicaid medical records, claims, and supporting documentation to evaluate medical necessity, level of care, utilization, length of stay, and documentation supporting services billed to Medicaid. Conducting clinical utilization reviews, which may include one-day inpatient stays, readmissions, extended lengths of stay, outlier cases, inpatient rehabilitation, psychiatric inpatient services, and other targeted reviews.

Evaluating whether the patient’s documented clinical condition supports the level of care and services billed. Applying professional nursing judgment, applicable Medicaid requirements, and nationally recognized clinical criteria, including InterQual when appropriate. Analyzing clinical documentation to identify unsupported or inappropriate services, potential overpayments, billing or utilization concerns, and potential indicators of fraud, waste, or abuse.

Clearly documenting clinical findings, rationale, and supporting evidence and contribute to case findings, notices, and other written documentation. Providing clinical expertise during case reviews, provider discussions, reconsiderations, settlement conferences, and other case-resolution activities as needed. Identifying trends or recurring concerns involving utilization, documentation, level of care, billing, reimbursement, or quality of care that may warrant additional review.

Maintaining accurate and timely case documentation and working knowledge of applicable Medicaid policies, provider manuals, clinical standards, and relevant state and federal healthcare requirements. Collaborating with nurses, investigators, auditors, analysts, managers, legal counsel, Medicaid program staff, healthcare providers, and other subject-matter experts and assist with their projects on an as needed basis. Participating in other clinical reviews, audits, and program-integrity activities based on emerging Medicaid risks and organizational priorities.