Investigator, SIU (Remote)

Lensa; Saint Petersburg (FL); 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 collaborating with various departments to ensure compliance. Candidates should have a degree in criminal justice and relevant experience, with strong analytical and investigative skills.

Qualifications

• 1-3 years of experience in investigation or related fields.
• Knowledge of law enforcement procedures and healthcare programs.
• Ability to multi-task and meet deadlines.

Responsibilities

• Conduct investigations on-site and desktop.
• Develop leads to assess potential fraud, waste, or abuse.
• Prepare audit results letters for providers.

Skills

Investigative skills

Analytical ability

Interpersonal skills

Communication skills

Critical thinking

Problem-solving

Education

Bachelor's or Associate’s Degree in criminal justice

Tools

Microsoft Office

SharePoint

Data management

Job description

2 days ago, be among the first 25 applicants.

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 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 to maintain coding accuracy and excellence. The position entails producing audit reports for internal and external review and may involve collaboration with other departments such as Compliance, Legal, and Medical Officers to ensure anti-fraud oversight.

Job Duties

1. Develop leads to assess potential fraud, waste, or abuse based on evidence.
2. Conduct preliminary assessments and full investigations, including witness interviews, background checks, data analytics, research, education, findings, and recommendations.
3. Complete investigations within mandated timeframes.
4. Conduct investigations on-site and desk top.
5. Review medical records and data to identify potential fraud, waste, or abuse.
6. Coordinate with internal departments to gather documentation.
7. Detect 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 coding and practices.
11. Interact with regulatory and law enforcement agencies.
12. Prepare audit results letters for providers.
13. Work may be remote, in-office, or involve travel within New York.
14. Ensure compliance with contractual and regulatory requirements.
15. Support SIU in legal procedures and settlements.
16. Participate in meetings and roundtables on FWA case development.

Job Qualifications

Required Education

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

Required Experience/Skills

• 1-3 years of experience, or as specified by contract.
• Investigative skills, analytical ability, objectivity.
• Knowledge of law enforcement procedures, healthcare programs, claim coding, and data analytics.
• Research and interpret regulatory requirements.
• Interpersonal and communication skills.
• Proficiency in Microsoft Office, SharePoint, and data management.
• Critical thinking, problem-solving, detail-oriented.
• Ability to multi-task and meet deadlines.

License and Certifications

• Valid driver’s license.

Preferred Experience and Certifications

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

Interested Molina employees should apply through the intranet. Molina offers competitive benefits. Equal Opportunity Employer. Pay range: $21.82 - $51.06/hour. Actual salary varies based on location, experience, and skills.