SIU Medical Coding Investigator

Molina Healthcare Inc; United States; Remote; USD 70,000 - 100,000; Full time

Job summary

Molina Healthcare Inc. is seeking an experienced professional to support the Special Investigation Unit (SIU) activities focused on medical provider CPT coding fraud, waste and abuse.

You will investigate post-payment claims against records and summarize findings for referral to authorities or recovery actions. This role requires strong CPT coding expertise, regulatory know-how, and the ability to manage multiple cases with accuracy.

Qualifications

• At least 2 years of CPT coding experience in a surgical, hospital and/or clinic setting.
• Certifications CPC, CCS, CPMA, or 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).

Responsibilities

• Independently re-evaluates medical claims and records using advanced coding knowledge and regulations.
• Reviews post-pay claims against records to determine accuracy of payments.
• Manages documents and prioritizes caseloads for timely turnaround.
• Ensures adherence to CPT guidelines, policies, and provider contracts.
• Devises clinical summaries post-review.
• Communicates and participates in meetings related to cases.
• Completes medical review to facilitate referrals to law enforcement or payment recovery.
• Supports investigation work as necessary per regulatory requirements.

Skills

Critical thinking

Analytical skills

Investigative procedures

Regulatory knowledge

Communication skills

Teamwork

Education

CPC

CCS

CPMA

AAPC certification

Tools

Microsoft Excel

Microsoft Office

Job description

Molina Healthcare Inc. is seeking an experienced professional to support the Special Investigation Unit (SIU) activities focused on medical provider CPT coding fraud, waste and abuse.

You will investigate post-payment claims against records and summarize findings for referral to authorities or recovery actions. This role requires strong CPT coding expertise, regulatory know-how, and the ability to manage multiple cases with accuracy.