Investigator, SIU (Remote)

Lensa; Grand Rapids (MI); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading career site is seeking a Special Investigation Unit (SIU) Investigator to support the prevention and investigation of healthcare fraud. This role involves conducting audits, collaborating with departments, and ensuring compliance with regulations. The ideal candidate will possess strong investigative skills and relevant experience, with a focus on fraud detection and reporting.

Qualifications

• 1-3 years of relevant experience or as required by state contract.
• Knowledge of billing codes, medical terminology, anatomy.
• Ability to multi-task and work independently.

Responsibilities

• Conduct preliminary assessments and full investigations.
• Prepare audit results letters for providers regarding overpayments.
• Document case information accurately in the case management system.

Skills

Investigative skills

Organization

Analysis

Objectivity

Knowledge of law enforcement procedures

Fraud investigations

Understanding of Managed Care

Data mining and analytics

Interpersonal skills

Analytical skills

Education

Bachelor’s or Associate’s Degree in criminal justice

Tools

Microsoft Office

SharePoint

Job description

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Lensa is the leading career site for job seekers at every stage of their career. Our client, Molina Healthcare, is seeking professionals. Apply via Lensa today!

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 reviews and analyzes information to draw conclusions on allegations of FWA and may determine the appropriateness of care. The role requires adherence to national and local coding and billing guidelines to maintain accuracy. The investigator also produces audit reports for internal and external review and collaborates with departments such as Compliance, Legal, and Medical Officers to ensure effective anti-fraud measures.

Job Duties

1. Develop leads to assess potential fraud, waste, or abuse, corroborating evidence.
2. Conduct preliminary assessments and full investigations, including witness interviews, background checks, data analytics, research, provider and member education, findings documentation, and case closure.
3. Complete investigations within mandated timelines per state and federal regulations.
4. Perform both on-site and desktop investigations.
5. Review medical records and data, determine if investigations identify fraud, waste, or abuse.
6. Coordinate with internal departments to gather documentation.
7. Identify aberrant billing patterns through utilization review to detect potential fraud.
8. Prepare referrals to regulatory agencies and law enforcement when needed.
9. Document case information accurately in the case management system, including case documentation storage.
10. Provide provider education on coding and billing practices based on guidelines.
11. Interact with regulatory and law enforcement agencies regarding investigations.
12. Prepare audit results letters for providers regarding overpayments.
13. Work remotely, in-office, and travel within New York as necessary.
14. Ensure compliance with contractual, federal, and state regulations.
15. Follow SIU policies and procedures, and support SIU goals.
16. Assist in legal procedures, arbitrations, and settlements.
17. Participate in MFCU meetings and FWA case development roundtables.

Job Qualifications

Required Education

Bachelor’s or Associate’s Degree in criminal justice or equivalent experience.

Required Experience/Skills

• 1-3 years of relevant experience or as required by state contract.
• Investigative skills, organization, analysis, objectivity.
• Knowledge of law enforcement procedures, fraud investigations.
• Understanding of Managed Care, Medicaid, Medicare, and Marketplace programs.
• Knowledge of billing codes, medical terminology, anatomy, healthcare systems.
• Data mining and analytics skills for fraud detection.
• Research and interpret regulatory requirements.
• Interpersonal and communication skills, including training delivery.
• Proficiency in Microsoft Office, SharePoint, and document merging.
• Analytical, critical thinking, problem-solving skills.
• Initiative, persistence, attention to detail.
• Understanding of audits and corrective actions.
• Ability to multi-task across boundaries.
• Self-motivated, deadline-oriented, goal tracking.
• Professional, ethical, team-oriented attitude.

Required License

• Valid driver’s license.

Preferred Experience

Over 5 years in FWA or related fields.

Preferred Certifications

• HCAFA, AHFI, CFE.

Current Molina employees should apply via the intranet. We offer competitive benefits. Molina is an EOE M/F/D/V.

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

Additional Details

• Seniority level: Mid-Senior level
• Employment type: Full-time
• Job functions: Other, IT, Management
• Industries: IT Services, Consulting

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