Investigator, SIU (Remote)

Lensa; Owensboro (KY); Remote; USD 10,000 - 60,000; Full time

Job summary

An established industry player is seeking a dedicated Special Investigation Unit Investigator to combat healthcare fraud, waste, and abuse. This pivotal role involves conducting thorough investigations, analyzing medical records, and collaborating with various departments to uphold compliance and ethical standards. You will be responsible for developing leads, performing audits, and educating providers on best practices. Join a dynamic team where your skills will contribute to significant anti-fraud measures and make a real impact in the healthcare sector. If you are passionate about investigative work and have a keen eye for detail, this opportunity is perfect for you.

Qualifications

• 1-3 years of experience in investigations or related fields.
• Strong investigatory skills and knowledge of fraud investigation procedures.
• Understanding of healthcare programs and billing codes.

Responsibilities

• Conduct investigations into healthcare fraud, waste, and abuse.
• Analyze data and prepare audit reports.
• Coordinate with internal teams and regulatory agencies.

Skills

Investigatory Skills

Data Analytics

Communication Skills

Problem-Solving Skills

Knowledge of Fraud Investigation Procedures

Understanding of Healthcare Programs

Interpersonal Skills

Presentation Skills

Time Management

High Ethical Standards

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 supports the prevention, detection, investigation, reporting, and recovery of funds related to healthcare fraud, waste, and abuse. Responsibilities include conducting accurate medical review audits, which may involve coding and billing reviews, analyzing information to assess allegations, and ensuring adherence to coding and billing guidelines. The role also involves producing audit reports and collaborating with internal departments such as Compliance, Legal, and Medical to maintain anti-fraud measures.

Job Duties

1. Develop leads to assess potential fraud, waste, or abuse based on evidence.
2. Conduct preliminary assessments and full investigations, including interviews, background checks, data analytics, research, education, and reporting.
3. Complete investigations within required timeframes as per regulations.
4. Perform on-site and desk investigations.
5. Review medical records and data to identify potential fraud, waste, or abuse.
6. Coordinate with internal teams to gather documentation.
7. Identify aberrant billing patterns through utilization review.
8. Prepare referrals to regulatory agencies and law enforcement.
9. Document case information accurately in case management systems.
10. Provide provider education on proper practices.
11. Interact with regulatory and law enforcement agencies.
12. Prepare audit result letters for providers regarding overpayments.
13. Work remotely, in-office, or travel within New York as needed.
14. Ensure compliance with contractual and regulatory requirements.
15. Support SIU in legal and arbitration processes.
16. Participate in meetings and case development activities.

Job Qualifications

Required Education

Bachelor's or Associate’s Degree in criminal justice or related field, or equivalent experience.

Required Experience/Skills

• 1-3 years of experience in investigations or related fields.
• Strong investigatory skills and knowledge of fraud investigation procedures.
• Understanding of healthcare programs, billing codes, and medical terminology.
• Experience with data analytics and regulatory research.
• Excellent communication, interpersonal, and presentation skills.
• Proficiency in Microsoft Office and SharePoint.
• Strong analytical and problem-solving skills.
• Ability to multi-task and meet deadlines.
• High ethical standards and professionalism.

Licenses and Certifications

• Valid driver’s license.

Preferred Experience and Certifications

• At least 5 years in FWA or related work.
• Certifications such as HCAFA, AHFI, or CFE are preferred.

Current Molina employees interested in this role should apply via the intranet. Molina offers competitive benefits. Equal Opportunity Employer. Pay Range: $21.82 - $51.06 hourly, varies by location and experience.

Additional Details

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