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

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

Salary

$70,455.00 - $73,000.00 Annually

Location

Richland County, SC

Job Type

FTE - Full-Time

Job Number

190235

Agency

Department of Health and Human Services

Division

Compliance and Performance Review

Opening Date

07/07/2026

Closing Date

8/7/2026 11:59 PM Eastern

Class Code:

EA18

Position Number:

60018429, 61096625

Normal Work Schedule:

Monday - Friday (8:30 - 5:00)

Pay Grade

CLN08

Hiring Range - Min.

$70,455.00

Hiring Range - Max.

$73,000.00

EEO Statement

Equal Opportunity Employer

Agency Specific Application Procedures:

Failure to provide detailed and complete information may result in your application not being referred.

Veteran Preference Statement

South Carolina is making our Veterans a priority for employment in state agencies and institutions.

• Description
• Benefits
• Questions

Job Responsibilities

Two (2) Positions Available

The Agencys mission is to be boldly innovative in improving the health and quality of life for South Carolinians.

This position is located in Medical Service Review, Richland County.

This is an in-office role and not a telecommute or remote position.

Are you the One? We are looking for a Registered Nurse, Non-Institutional (Nurse Investigator) who, in a NON-CLINICAL setting, identifies fraud, waste, and abuse in the Medicaid Program by reviewing post paid claims. Conducts post-payment reviews of medical providers. Identifies and recovers excessive and inaccurate payments to providers and ensure compliance with the applicable Medicaid laws, regulations, and policies. Performs Data analysis of post paid claims.

• Develop case reviews to include as determined 1) conduct unannounced onsite visit and obtain medical records, 2) Request medical records 3) send provider/recipient survey letters 4) send provider self-audit letter, 5) request additional information or documentation or 6) make telephone calls to recipients to verify services 7) Coordinate and correspond case actions with Managed Care Organizations (referring providers timely), 8) Coordinate and correspond cases and complaints with the Investigator 9) Coordinate, correspond and assist in Agency's special projects (TPL, HYDE, etc.) and contractor reviews such as UPIC, RAC, etc. Review all information received and do a comparison review between the Medicaid paid claims, applicable Medicaid rules, regulations and policy and all documentation or information obtained. Verify appropriateness and medical necessity of services billed to Medicaid. Determine if fraud referral is warranted and coordinate with supervisor to complete a referral to SC Medicaid Fraud Control Unit (SCMFCU) when fraud is suspected.
• Evaluate paid claims history data and determine the following: 1) patterns of practice and adherence to Medicaid program policy and procedures; 2) research information and make decisions utilizing nursing knowledge and expertise in evaluating health delivery patterns of individual providers and specialties; 3) use appropriate methodology to conduct comparison studies, focus reviews, and random sampling , review universe of claims, self-audit, line by line sample or random sampling. Assist in evaluating the SURS algorithms used for payment analytics to determine their validity for recoupment from MCOs and/or providers. This includes researching applicable policies to confirm the accuracy and appropriateness of each algorithm and, when needed, consulting with the policy division for clarification or guidance.
• Learn and utilize the current (BIS) Business Information Systems (SAS, MMIS etc.) and SURS department. Ability to develop special reports in accordance with current health trends and practices utilizing requisite nursing/dental/professional medical knowledge. Run DCRs (detailed claims Excel report), and focused reports on paid claims data as needed in SAS. Be able to utilize SAS to identify providers with egregious billing by researching Fraud Framework. Conducts evaluation and analysis of provider statistical profiles and detail claims reports generated by SURS/SAS reporting system. Be able to research and triage Alerts in SAS Fraud Framework. The first line review of data includes analysis and evaluation of exception criteria and profile reports as well as generating reports of paid claims data. Assist in evaluating the SURS algorithms used for payment analytics to determine their validity for recoupment from MCOs and/or providers. This includes researching applicable policies to confirm the accuracy and appropriateness of each algorithm and, when needed, consulting with the policy division for clarification or guidance.
• Coordinates case actions with supervisor, program area staff and investigator when indicated. Identify and describe the providers aberrant billing pattern/billing errors within the findings letter and on the Detailed claims report, cite and/or include in the initial findings packet, the policy which validates the errors and make provider recommendations to prevent the improper billing from occurring in the future. Set up AR (accounts receivable) when sending 30-day letter and track for appeal at 40-day mark. Monitors case progression at 15 day and 35-day intervals and respond to providers, as necessary. Co-ordinate cases with MCOs, UPIC, RAC and DQ when applicable. Draft 30-day letter for UPIC and send it to the provider and track for appeal prior to closing and setting up AR (Accounts receivable).
• Coordinate or schedule an informal conference to discuss review findings when requested by the provider and defend cases in fair hearing. Coordinate pre-hearing meeting with the pertinent agency staff to include Office of General Counsel and program area representative. Document the informal conference or appeals process. Co-ordinate informal meetings, Pre-hearing conferences, and appeal hearings between State, UPICs, RACs, DQ and MCOs. Refer providers to other agencies, Managed Care Organizations or the relevant licensing board as deemed appropriate.

The South Carolina Department of Health and Human Services offers an exceptional benefits package for FTE and TGE positions that includes:

• 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

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 drivers license.
• Requires holder to drive routinely.
• Sitting or standing for long periods of time.
• Lifting requirements: 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.
• Ability to communicate effectively.
• The ability to multi-task within time frames and prioritize cases utilizing effective time management skills.
• Must possess and apply computer proficiency and knowledge of Microsoft Excel and Word.
• Must be able to perform web-based software functions (pull documents from online database, run data reports, upload documents in electronic case management system, etc.).
• Will work under limited supervision in conformance with established policies and procedures.
• Coordinate fraud cases with MCOs and the Attorney Generals Office.

Additional Comments

Please complete the State application to include all current and previous work history and education. A resume will not be accepted nor reviewed to determine if an applicant has met the qualifications for the position. Supplemental questions are considered part of your official application for qualification purposes. All applicants must apply online. All correspondence from the Office of Human Resources will be through electronic mail.

The South Carolina Department of Health and Human Services is committed to providing equal employment opportunities to all applicants and does not discriminate on the basis of race, color, religion, sex (including pregnancy, childbirth or related medical conditions, including, but not limited, to lactation), national origin, age (40 or older), disability or genetic information.

Benefits for State Employees

The state of South Carolina offers eligible employees generous benefits, including health and dental insurance; retirement and savings plan options; and paid vacation and sick leave. Plus, work-life balance programs such as telecommuting and flexible work schedules are available to employees of some state agencies.

Insurance Benefits

Eligible employees may enroll in health insurance, which includes prescription coverage and wellness benefits. Other available insurance benefits include dental, vision, term life insurance, long term disability and flexible spending accounts for health and child care expenses.

Retirement Benefits

State employees are also offered retirement plan options, including defined benefit and defined contribution plans. Additionally, eligible employees may elect to participate in the South Carolina Deferred Compensation Program, which is a voluntary, supplemental retirement savings plan offering 401(k) and 457 plan options.

Workplace Benefits

State employees may also be eligible for other benefits, including tuition assistance; holiday, annual and sick leave; and discounts on purchases, travel and more.

Note: The benefits above are available to most state employees, with the exception of those in temporary positions. Employees in temporary grant and time-limited positions may be eligible for all, some or none of these benefits as benefits are associated with each position type. For these positions, contact the hiring agency to determine what benefits may be available.

01

The responses you provide to these Supplemental Questions will be used in combination with your application to determine whether you meet the minimum qualification requirements. Please, thoroughly complete the Education and Work Experience sections of your application and the Supplemental Questions. Failure to provide detailed and complete information will result in your application being rejected. Any misrepresentation or omissions will result in your disqualification from employment and/or termination. You may not submit resumes in lieu of filling out the application or answering the Supplemental Questions. I acknowledge that I have read, understand, and agree with the above.

• Yes
• No

02

The established hiring range for this position is $70,455 to $73,000. Do you accept this range?

• Yes
• No

03

Did you graduate from an accredited school of nursing?

• Yes
• No

04

Do you have two (2) years of clinical experience in a nursing setting?

• Yes
• No

05

Do you have a current licensure as a Registered Nurse by the State Board of Nursing for South Carolina? If yes, please provide your Nursing license number.

06

Do you have a valid drivers license? If yes, please provide your drivers license number and state of issuance.

07

Do you wish to claim Veteran Preference? If yes, you must submit a copy of your DD214 Form with your job application in order to qualify and claim this preference.

• Yes
• No

08

How did you hear about this career opportunity?

Required Question

Employer State of South Carolina

Agency Department of Health and Human Services Address 1801 Main Street, Suite 224

Columbia, South Carolina, 29201

Phone 803-898-2670

The language used in this document does not create an employment contract between the employee and the agency. This document does not create any contractual rights or entitlements. The agency reserves the right to revise the content of this document, in whole or in part. No promises or assurances, whether written or oral, which are contrary to or inconsistent with the terms of this paragraph create any contract of employment.