Investigator, SIU (Remote)

Lensa; Austin (TX); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading company is seeking a Special Investigation Unit (SIU) Investigator to support the prevention and investigation of healthcare fraud, waste, and abuse. The role involves conducting audits, analyzing data, and preparing reports. Ideal candidates will have strong investigatory and analytical skills, with a background in criminal justice. This full-time position offers competitive pay and may involve remote work.

Qualifications

• 1-3 years of experience required, unless otherwise specified.
• Knowledge of Managed Care, Medicaid, and Medicare systems.
• Familiarity with data mining and analytics for fraud detection.

Responsibilities

• Conducts investigations into fraud, waste, and abuse allegations.
• Prepares audit reports and documentation for internal and external review.
• Coordinates with internal departments for investigation support.

Skills

Investigatory skills

Analytical skills

Communication skills

Problem-solving skills

Interpersonal skills

Education

Bachelor's degree in criminal justice

Associate’s Degree in criminal justice

Tools

Microsoft Office

SharePoint

Job description

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Job Description

Job Summary

The Special Investigation Unit (SIU) Investigator is responsible for supporting the prevention, detection, investigation, reporting, and when appropriate, recovery of money related to health care fraud, waste, and abuse. Duties include performing accurate and reliable medical review audits that may also include coding and billing reviews. The SIU Investigator is responsible for reviewing and analyzing information to draw conclusions on allegations of FWA and/or may determine appropriateness of care. The SIU Investigator is also responsible for recognizing and adhering to national and local coding and billing guidelines in order to maintain coding accuracy and excellence. The position also entails producing audit reports for internal and external review. The position may also work with other internal departments, including Compliance, Corporate Legal Counsel, and Medical Officers in order to achieve and maintain appropriate anti-fraud oversight.

Job Duties

1. Responsible for developing leads presented to the SIU to assess and determine whether potential fraud, waste, or abuse is corroborated by evidence.
2. Conducts both preliminary assessments of FWA allegations, and end to end full investigations, including but not limited to witness interviews, background checks, data analytics to identify outlier billing behavior, contract and program regulation research, provider and member education, findings identification and communications development, and recommendations and preparation of overpayment identifications and closure of investigative cases.
3. Completes investigations within the mandated period of time required by either state and/or federal contracts and/or regulations.
4. Conducts both on-site and desk top investigations.
5. Conducts low to medium, and extensive investigations, including reviews of medical records and data analysis, and makes determinations as to whether the investigation and/or audit identified potential fraud, waste, or abuse.
6. Coordinates with various internal customers (e.g., Provider Services, Contracting and Credentialing, Healthcare Services, Member Services, Claims) to gather documentation pertinent to investigations.
7. Detects potential health care fraud, waste, and abuse through the identification of aberrant coding and/or billing patterns through utilization review.
8. Prepares appropriate FWA referrals to regulatory agencies and law enforcement.
9. Documents all case-related information in the case management system accurately, including storage of case documentation following SIU requirements. Prepares detailed investigation referrals to regulatory and law enforcement agencies when potential fraud, waste, or abuse is identified.
10. Provides provider education on appropriate practices (e.g., coding) based on national or local guidelines, contractual, and/or regulatory requirements.
11. Interacts with regulatory and law enforcement agencies regarding case investigations.
12. Prepares audit results letters to providers when overpayments are identified.
13. Work may be remote, in-office, and involve travel within New York state as needed.
14. Ensures compliance with contractual, federal, and state regulations.
15. Supports SIU in legal procedures, arbitrations, and settlements.
16. Participates in MFCU meetings and roundtables on FWA case development and referral.

Job Qualifications

Required Education

Bachelor's degree or Associate’s Degree in criminal justice or an equivalent combination of education and experience.

Required Experience/Knowledge, Skills & Abilities

• 1-3 years of experience, unless otherwise required by state contract.
• Proven investigatory skills; ability to organize, analyze, and determine risk with solutions; objectivity in fact-finding.
• Knowledge of investigative procedures and law enforcement, especially regarding fraud investigations.
• Knowledge of Managed Care, Medicaid, Medicare, and Marketplace programs.
• Understanding of claim billing codes, medical terminology, anatomy, and healthcare systems.
• Familiarity with data mining and analytics for fraud detection.
• Ability to interpret regulatory requirements.
• Strong interpersonal, communication, and presentation skills.
• Proficiency in Microsoft Office, SharePoint, and internet tools.
• Analytical, critical thinking, and problem-solving skills.
• Initiative, persistence, and detail-oriented approach.
• Ability to multi-task and work across boundaries.
• Self-motivated with the ability to meet deadlines.
• Understanding of audits and corrective actions.
• Team-oriented with a professional demeanor.

Required License, Certification, Association

• Valid driver’s license.

Preferred Experience

At least 5 years in FWA or related work.

Preferred License, Certification, Association

• HCAFA
• AHFI
• CFE

To current Molina employees: Apply through the intranet.

Molina offers competitive benefits. EOE M/F/D/V.

Pay Range: $21.82 - $51.06/hour. Actual pay varies by location, experience, education, and skills.

Seniority level

• Mid-Senior level

Employment type

• Full-time

Job function

• Other, IT, Management

Industries

• IT Services and Consulting

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