Nurse Investigator

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The mission of the Department of Law is to serve the citizens of the State of Georgia by providing legal representation of the highest quality to the agencies, officers and employees of state government and by honorably and vigorously carrying out the constitutional and statutory responsibilities of the Attorney General. 

Job Summary:

Under the direction of the Fraud Unit Director, assists in healthcare investigations by: reviewing provider and recipient records, by making determinations of medical necessity, by making determinations as to whether services were provided and properly documented, and by making determinations as to whether proper diagnostic and procedure codes were used in submitting claims to the Georgia Medicaid Program. Maintains a comprehensive understanding of current policies and procedures of the Georgia Medicaid Program. Participates as a member of an interdisciplinary team in Healthcare fraud investigations, and provides support to members of other disciplines in such investigations. Participates in interviews of subjects and witnesses, and prepares written summaries of such interviews. Prepares written reports of findings and opinions as directed by the prosecutor. May testify as a witness in grand jury and trial court proceedings.

DUTIES AND RESPONSIBILITIES:

  • Maintains a comprehensive knowledge of the policies and procedures of the Georgia Medicaid Program.
    • Demonstrates thorough knowledge of and insures compliance with departmental policies and procedures governing the Georgia Medicaid Program; state and federal laws and policies governing Medicare and Medicaid.
    • Applies appropriate regulations, policies, and procedures to accurately determine reimbursable services and eligibility of providers as requested.
  • Assists prosecutors in Healthcare Fraud investigations by reviewing provider and patient records.
    • Makes determination of medical necessity, quality of services, and appropriateness of services rendered based on chart review and client interview and assessment.
    • Maintains a current repository of medically related information and departmental policies and procedures specific to the target groups reviewed.
    • Documents non-compliance with Departmental, Federal and State policies and procedures and current standards and practices of medical documentation monitoring activities.
    • Reviews medical/clinical records for meeting criteria for authorized services.

 

  • Participates in investigations as a member of an interdisciplinary team.
    • Determines records to be reviewed.
    • Reviews records appropriate to each program and provider audited.
    • Determines program compliance and deficiencies according to established guidelines.
    • Provides immediate feedback to staff regarding any blatant compliance issues.
    • Accurately documents findings from audit on standard forms.
  • Participates in interviews of subjects and witnesses, and prepares written summaries of such interviews.
  • Prepares written reports of findings and opinions as directed by the prosecutor.
  • May testify as a witness in grand jury and trial court proceedings.

 

The above statements are intended to describe the general nature and level of work being performed by persons assigned to this title.  They may not include all job duties performed by employees on this job title, and every position does not necessarily require these duties.

Minimum Qualifications:

Current RN license in the State of Georgia and demonstrated experience in the analysis of Medicaid/Medicare claims.

Preferred Qualifications:

Experience in one or more of the following: 1) Specific, additional experience in the analysis of medical services documentation and related claims; 2) Utilization Review; 3) Case Management; 4) Analysis of CPT codes and/or ICD-10 Diagnosis Codes; and or 5) Medical Billing.

SALARY COMMENSURATE WITH EXPERIENCE

 

ADDITIONAL INFORMATION:

A criminal background check is completed on all candidates; employment is also contingent upon the completion and satisfactory results of the background investigation.  Candidates strongly considered for the position will also be required to submit a Department of Law employment application and waiver, Georgia Department of Revenue Tax Clearance letter and copies of official college transcripts.

The Office of THE ATTORNEY GENERAL does not discriminate on the basis of race, color, national origin, sex, religion, age or disability in employment or services.

Nurse Investigator