Medical Claims Fraud Investigator – SIU Coding

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

Job summary

Molina Healthcare is seeking a professional to support the Special Investigation Unit (SIU) focusing on medical provider coding fraud, waste and abuse. You will re-evaluate post-payment claims, review medical records for accuracy, and ensure adherence to CPT guidelines and provider contracts.

The role requires CPT coding expertise, regulatory knowledge, and strong analytical skills, with the ability to manage multiple investigations and collaborate with legal and compliance teams.

Qualifications

• 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.

Responsibilities

• 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, 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.

Skills

CPT coding

Analytical thinking

Investigation procedures

Regulatory compliance

Healthcare claims knowledge

Communication skills

MS Excel

Education

CPC

CCS

CPMA

AAPC certifications

Tools

Claims processing systems

Microsoft Excel

Job description

Molina Healthcare is seeking a professional to support the Special Investigation Unit (SIU) focusing on medical provider coding fraud, waste and abuse. You will re-evaluate post-payment claims, review medical records for accuracy, and ensure adherence to CPT guidelines and provider contracts.

The role requires CPT coding expertise, regulatory knowledge, and strong analytical skills, with the ability to manage multiple investigations and collaborate with legal and compliance teams.