Investigator, Special Investigative Unit Coding (Remote)

Molina Talent Acquisition; New York (NY); Remote; USD 85,000 - 110,000; Full time

Benefits offered by this job

Competitive benefits

Job summary

Molina Healthcare is seeking a dedicated investigator to support the Special Investigations Unit (SIU) with medical coding fraud, waste and abuse reviews. You will analyze CPT coding, review post-payment claims, and prepare case materials for potential law enforcement action.

The role demands strong analytical, regulatory, and communication skills, with experience in Medicare/Medicaid programs and proficiency in Excel.

Qualifications

• Minimum 2 years CPT coding in medical setting.
• CPC/CCS/CPMA or AAPC certification.
• Strong analytical, problem-solving, and communication skills.
• Knowledge of fraud investigations and regulatory requirements.
• Experience with Medicaid/Medicare and other programs.
• Ability to manage multiple tasks and work in a team.
• Proficiency in Microsoft Office and relevant software.

Responsibilities

• Re-evaluates medical claims and records using CPT coding and regulations.
• Reviews post-pay claims against medical records for payment accuracy.
• Manages documents and prioritizes caseloads for timely turnaround.
• Adheres to CPT guidelines, policies, and provider contracts.
• Creates clinical summaries post-review for investigations.
• Participates in meetings and communicates case updates.
• Completes medical reviews to support referrals to law enforcement or recovery.
• Supports investigation work as required by regulators.

Skills

CPT coding knowledge

Fraud investigations experience

Analytical skills

Regulatory knowledge (Medicare/MedICAi

Communication skills

Microsoft Excel

Education

CPC/CCS/CPMA or AAPC certification

Tools

Excel

Claims processing systems

Job description

JOB DESCRIPTION

Provides support for special investigation unit (SIU) activities specific to medical provider coding fraud, waste and abuse (FWA). Investigates and resolves instances of health care fraud and abuse investigations of medical providers using informational tips from member benefits and medical records following review of post-payment claims.

Essential Job Duties

• Independently re-evaluates medical claims and associated records by applying knowledge of advanced coding, applicable federal and state regulatory requirements, and Molina policies.
• Reviews post-pay claims against corresponding medical records to determine accuracy of claims payments.
• Manages documents and prioritizes caseloads to ensure timely turnaround.
• Ensures adherence to applicable state/federal/internal policies, Current Procedural Terminology (CPT) guidelines and provider contract requirements.
• Devises clinical summary post-review.
• Communicates and participates in meetings related to cases.
• Completes medical review to facilitate referral to law enforcement or payment recovery.
• Supports investigation work as necessary and required by the regulatory agency.

Job Requirements

• At least 2 years of CPT coding experience in a surgical, hospital and/or clinic setting, or equivalent combination of relevant education and experience.
• Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Professional Medical Auditor (CPMA), or American Academy of Professional Coders (AAPC) certified.
• Critical-thinking, problem-solving and analytical skills.
• Knowledge of investigative and law enforcement procedures with emphasis on fraud investigations.
• Knowledge of managed care and the Medicaid, Medicare, and Marketplace programs.
• Understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems.
• Ability to research and interpret regulatory requirements.
• Ability to prioritize and manage multiple tasks.
• Ability to work in a team setting.
• Strong verbal/written communication skills, and presentation skills.
• Microsoft Office suite (including Excel), and applicable software program(s) proficiency.
• In some states, 5 years of experience working in a fraud, waste and abuse (FWA)/special investigations unit (SIU)/fraud investigations role may be required (dependent on state/contractual requirements).

Preferred Qualifications

• Certified Professional Compliance Officer (CPCO).Certified Fraud Examiner (CFE) and/or Accredited Health Care Fraud Investigator (AHFI).
• Experience working in group health insurance, particularly within claims processing or operations.
• Working knowledge of local, state and federal laws and regulations pertaining to health insurance, investigations and legal processes (commercial insurance, Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, etc.).
• Experience with claims processing systems.
• Ability to use Microsoft Excel platform and work with large quantities of data.
• Ability to answer questions, identify trends and patterns, and present findings".

Molina Healthcare offers a competitive benefits and compensation package.

Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V