SIU Coding Investigator: Fraud & FWA

Molina Talent Acquisition; United States; Remote; USD 65,000 - 90,000; Full time

Job summary

Molina Healthcare is seeking a skilled investigator specializing in medical provider coding fraud, waste, and abuse (FWA) within the SIU. You will re-evaluate claims using CPT coding knowledge and applicable federal/state regulations, reviewing post-pay claims against records to ensure payment accuracy.

Responsibilities include prioritizing caseloads, preparing clinical summaries, and supporting investigations for potential referrals or recovery, with emphasis on compliance and collaboration in

Qualifications

• At least 2 years of CPT coding experience in a surgical, hospital and/or clinic setting.
• Certified CPC/CCS/CPMA or AAPC certification.
• Strong analytical, problem-solving and research abilities.
• Knowledge of investigative and law enforcement procedures with emphasis on fraud investigations.

Responsibilities

• Independently re-evaluates medical claims and records using advanced coding knowledge and regulatory requirements.
• Reviews post-pay claims against medical records to verify payment accuracy.
• Manages caseload documents and prioritizes for timely turnaround.
• Ensures adherence to CPT guidelines and provider contracts.
• Devises clinical summaries post-review for referrals or recoveries.
• Supports investigation work as required by regulatory agencies.

Skills

CPT coding knowledge

Critical thinking

Analytical skills

Communication skills

Team player

Microsoft Excel

Education

CPC/CCS/CPMA or AAPC certification

Tools

Claims processing systems

Microsoft Excel

Job description

Molina Healthcare is seeking a skilled investigator specializing in medical provider coding fraud, waste, and abuse (FWA) within the SIU. You will re-evaluate claims using CPT coding knowledge and applicable federal/state regulations, reviewing post-pay claims against records to ensure payment accuracy.

Responsibilities include prioritizing caseloads, preparing clinical summaries, and supporting investigations for potential referrals or recovery, with emphasis on compliance and collaboration in