Nurse Investigator

State of Utah Office of the Governor • Salt Lake City, UT

4d • $32 - $47 • Hybrid

About The Position

The Utah Office of Inspector General of Medicaid Services (OIG) is seeking 2 experienced Registered Nurses to join its Program Integrity team. In this position, you will use your clinical knowledge, professional nursing judgment, and critical-thinking skills to review healthcare services provided to Medicaid members. You will independently evaluate clinical information and provide nursing expertise to support the OIG’s responsibility for protecting the integrity of the Medicaid program.

Requirements

• Current licensure as a Registered Nurse (RN) in the State of Utah.
• Clinical nursing knowledge and experience sufficient to independently review and interpret medical records and clinical documentation.
• Ability to exercise professional nursing judgment and apply critical thinking and reasoning when evaluating complex clinical information.
• Ability to read, analyze, and draw appropriate conclusions from medical records and other written information.
• Ability to clearly communicate clinical findings and supporting rationale, both verbally and in writing.
• Ability to work independently, organize and prioritize assignments, and meet established deadlines.
• Ability to appropriately handle confidential information and protected health information.
• Ability to successfully complete required background screening.

Nice To Haves

• Experience in utilization review, utilization management, medical necessity review, clinical documentation review, healthcare auditing, or program integrity.
• Acute-care hospital nursing experience, including inpatient nursing, emergency services, critical care, case management, or a related clinical area.
• Experience conducting inpatient utilization or level-of-care reviews.
• Experience using InterQual, MCG, or another nationally recognized medical-necessity or level-of-care criteria set.
• Experience with Medicaid, Medicare, or another healthcare payer, including healthcare coverage, claims, reimbursement, utilization management, auditing, or compliance.
• Behavioral-health experience, including psychiatric inpatient services, substance-use-disorder services, behavioral-health utilization review, or other behavioral healthcare.
• Experience reviewing healthcare claims, medical records, billing documentation, coding, or reimbursement.

Responsibilities

• 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.

Benefits

• This position is eligible for a full benefits package.
• Job Stability: Enjoy the security and reliability of employment within a well-established organization.
• Career Growth: Develop valuable skills and gain opportunities for leadership within a large organization.
• Meaningful Work: Contribute to an important service that benefits the community and supports organizational goals.
• Supportive Work Environment: Be part of a team that values cooperation, strong work ethics, and mutual support.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level