Investigator, Special Investigative Unit Coding (Remote)

Molina Healthcare

United States

Remote

Who this role is best for

Best suited to certified coders with fraud investigation experience working in the healthcare domain.

Best fit for

Certified coders with 2+ years of experience in surgical, hospital, or clinic settings
— “At least 2 years of CPT coding experience in a surgical, hospital and/or clinic setting”
Candidates with knowledge of Medicaid, Medicare, and fraud investigation procedures
— “Knowledge of investigative and law enforcement procedures with emphasis on fraud investigations”
Proficient in medical terminology and claim billing codes with attention to detail
— “Understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems”

Things to consider

Some states may require 5 years of FWA/SIU experience, not just 2 years
— “In some states, 5 years of experience working in a fraud, waste and abuse (FWA)/special investigations unit (SIU)/fraud investigations role may be required”
The role requires independent work and strong communication skills for case discussions
— “Communicates and participates in meetings related to cases”

How to stand out

Emphasize experience with post-payment claims reviews and fraud detection
— “Independently re-evaluates medical claims and associated records”
Highlight knowledge of federal and state regulatory requirements in your resume
— “applying knowledge of advanced coding, applicable federal and state regulatory requirements”
Demonstrate ability to manage caseloads and prioritize tasks effectively
— “Manages documents and prioritizes caseloads to ensure timely turnaround”
Showcase experience with Microsoft Excel and data analysis in your application materials
— “Ability to use Microsoft Excel platform and work with large quantities of data”
Mention any relevant certifications like CFE or AHFI if available
— “Certified Fraud Examiner (CFE) and/or Accredited Health Care Fraud Investigator (AHFI)”

Pace · SteadyCollaboration · HighAutonomy · MediumDecision Impact · Team

Derived from job-description analysis by Serendipath's career intelligence engine.

What success looks like

Re-evaluating medical claims and associated records
Managing documents and prioritizing caseloads
Ensuring adherence to applicable state/federal/internal policies
Completing medical review to facilitate referral to law enforcement or payment recovery

Typical background

At least 2 years of CPT coding experienceCertified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Professional Medical Auditor (CPMA), or American Academy of Professional Coders (AAPC) certified

Skills & requirements

Required

CPT CodingKnowledge Of Investigative And Law Enforcement ProceduresKnowledge Of Managed CareAbility To Research And Interpret Regulatory RequirementsAbility To Prioritize And Manage Multiple TasksAbility To Work In A Team SettingStrong Verbal/written Communication SkillsProficiency In Microsoft Office Suite

Preferred

Certified Professional Compliance Officer (cpco)Certified Fraud Examiner (cfe)Accredited Health Care Fraud Investigator (ahfi)Experience With Claims Processing SystemsAbility To Use Microsoft Excel Platform And Work With Large Quantities Of DataAbility To Answer Questions, Identify Trends And Patterns, And Present Findings

Stack & domain

CPT CodingMedical ClaimsMedical RecordsFraud InvestigationsRegulatory RequirementsMedical TerminologyAnatomyHealth Care Delivery SystemsMicrosoft Office SuiteExcelClaims Processing SystemsCritical-thinkingProblem-solvingAnalytical SkillsCommunicationTeamworkPrioritizationTime ManagementPresentation SkillsCPCCCSCPMAAAPCCPCOCFEAHFIHealthcareMedicaidMedicareMarketplace ProgramsLegal Processes

About the role

Original posting from Molina Healthcare

JOB DESCRIPTION
Provides support for special investigation unit (SIU) activities specific to medical provider coding fraud, waste and abuse (FWA). Investigates and resolves instances of health care fraud and abuse investigations of medical providers using informational tips from member benefits and medical records following review of post-payment claims.
Essential Job Duties
Independently re-evaluates medical claims and associated records by applying knowledge of advanced coding, applicable federal and state regulatory requirements, and Molina policies.
Reviews post-pay claims against corresponding medical records to determine accuracy of claims payments.
Manages documents and prioritizes caseloads to ensure timely turnaround.
Ensures adherence to applicable state/federal/internal policies, Current Procedural Terminology (CPT) guidelines and provider contract requirements.
Devises clinical summary post-review.
Communicates and participates in meetings related to cases.
Completes medical review to facilitate referral to law enforcement or payment recovery.
Supports investigation work as necessary and required by the regulatory agency.
Job Requirements
At least 2 years of CPT coding experience in a surgical, hospital and/or clinic setting, or equivalent combination of relevant education and experience.
Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Professional Medical Auditor (CPMA), or American Academy of Professional Coders (AAPC) certified.
Critical-thinking, problem-solving and analytical skills.
Knowledge of investigative and law enforcement procedures with emphasis on fraud investigations.
Knowledge of managed care and the Medicaid, Medicare, and Marketplace programs.
Understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems.
Ability to research and interpret regulatory requirements.
Ability to prioritize and manage multiple tasks.
Ability to work in a team setting.
Strong verbal/written communication skills, and presentation skills.
Microsoft Office suite (including Excel), and applicable software program(s) proficiency.
In some states, 5 years of experience working in a fraud, waste and abuse (FWA)/special investigations unit (SIU)/fraud investigations role may be required (dependent on state/contractual requirements).
Preferred Qualifications
Certified Professional Compliance Officer (CPCO).Certified Fraud Examiner (CFE) and/or Accredited Health Care Fraud Investigator (AHFI).
Experience working in group health insurance, particularly within claims processing or operations.
Working knowledge of local, state and federal laws and regulations pertaining to health insurance, investigations and legal processes (commercial insurance, Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, etc.).
Experience with claims processing systems.
Ability to use Microsoft Excel platform and work with large quantities of data.
Ability to answer questions, identify trends and patterns, and present findings.
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

Source: Molina Healthcare careers