Investigator, SIU (Remote)

Lensa; Saint Petersburg (FL); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading career site is seeking a Special Investigation Unit (SIU) Investigator responsible for preventing and investigating healthcare fraud, waste, and abuse. The role involves conducting investigations, analyzing data, and collaborating with internal departments to ensure compliance. Candidates should have a degree in criminal justice and relevant experience, with strong analytical and communication skills.

Qualifications

• 1-3 years of relevant experience required.
• Preferred 5+ years in FWA or related work.
• Certifications HCAFA, AHFI, or CFE preferred.

Responsibilities

• Conduct investigations including interviews and data analysis.
• Review medical records to identify potential fraud.
• Prepare audit reports and interact with regulatory agencies.

Skills

Investigatory skills

Analytical ability

Objectivity

Knowledge of fraud investigation procedures

Understanding of medical coding

Strong communication skills

Interpersonal skills

Detail-oriented

Team-oriented

Education

Bachelor’s or Associate’s Degree in criminal justice

Tools

Microsoft Office

Data merging tools

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 is responsible for reviewing and analyzing information to draw conclusions on allegations of FWA and/or may determine appropriateness of care. The position also entails producing audit reports for internal and external review. The position may also work with other internal departments, including 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 investigations, including interviews, background checks, data analysis, research, education, and reporting.
3. Complete investigations within mandated timeframes.
4. Conduct both on-site and desk investigations.
5. Review medical records and data to identify potential fraud, waste, or abuse.
6. Coordinate with internal departments 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 and prepare investigation reports.
10. Provide provider education on coding and practices.
11. Interact with regulatory and law enforcement agencies.
12. Prepare audit results letters for providers.
13. Travel within New York as needed; work remotely or in-office.
14. Ensure compliance with applicable regulations and policies.
15. Support legal procedures and participate in meetings 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 relevant experience.
• Investigatory skills, analytical ability, objectivity.
• Knowledge of fraud investigation procedures, managed care, and healthcare programs.
• Understanding of medical coding, terminology, and data analytics.
• Strong communication and interpersonal skills.
• Proficiency in Microsoft Office and data merging tools.
• Detail-oriented and able to meet deadlines.
• Team-oriented with high ethical standards.

License/Certification

• Valid driver’s license.

Preferred Experience

5+ years in FWA or related work.

Preferred Certifications

• HCAFA, AHFI, or CFE.

To apply, current Molina employees should use the intranet. Molina offers competitive benefits. Equal Opportunity Employer. Pay Range: $21.82 - $51.06/hour. Actual pay varies by location, experience, and skills.