Investigator, Special Investigative Unit Coding (Remote)

Molina Healthcare; United States; Remote; USD 41,000 - 88,000; Full time

Job summary

Molina Healthcare is seeking an SIU investigator to support medical provider coding fraud, waste and abuse investigations. You will re-evaluate claims, review records, and apply CPT coding knowledge within Molina policies and federal/state regulations.

This role requires strong analytical and communication skills, experience with fraud investigations, and proficiency in Microsoft Office. You will manage a caseload, prioritize tasks, and collaborate with teams to drive timely resolutions and

Qualifications

• At least 2 years of CPT coding experience in a surgical, hospital or clinic setting.
• Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Professional Medical Auditor (CPMA), or AAPC certified.
• Strong 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 proficiency (including Excel).
• In some states, 5 years of experience in FWA/SIU/fraud investigations may be required.

Responsibilities

• Independently re-evaluates medical claims and records using advanced coding knowledge and policies.
• Reviews post-pay claims against records to determine payment accuracy.
• Manages documents and prioritizes caseloads for timely turnaround.
• Ensures adherence to CPT guidelines and provider contracts.
• Devises clinical summaries 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 required by the regulatory agency.

Skills

CPT coding

CPC certification

CCS certification

CPMA certification

AAPC certification

Critical thinking

Analytical skills

Investigation procedures

Fraud investigations

Microsoft Excel

Teamwork

Communication skills

Claims processing systems

Tools

Microsoft Office

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

Pay Range: $19.64 - $42.55 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.