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The Role
Conduct post-payment medical claim reviews to detect provider coding fraud, waste, and abuse. Apply CPT and regulatory knowledge to re-evaluate claims, manage caseloads, produce clinical summaries, support referrals for recovery or law enforcement, and participate in investigative meetings.
Summary Generated by Built In
JOB DESCRIPTION
Provides investigative 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, all relevant and 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
- Associates in criminal justice or degree. If no Degree:
- 5-7 Years of Health Care Claims Investigations
- 5-7 Years of previous SIU Investigations
- Previous Law Enforcement
- At least 2 years 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.
- 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).
- 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.
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/Access platforms working with large quantities of data.
- Ability to answer questions, identify trends and patterns, and present findings.
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To all current Molina employees. If you are interested in applying for this position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
Skills Required
- Associate degree in Criminal Justice or equivalent degree
- 5-7 years Health Care Claims Investigations (required if no degree)
- 5-7 years previous SIU investigations experience (required if no degree)
- Previous law enforcement experience
- At least 2 years CPT coding experience in surgical, hospital and/or clinic setting
- Certification: CPC, CCS, CPMA, or AAPC certification
- Knowledge of investigative and law enforcement procedures with emphasis on fraud investigations
- Knowledge of Managed Care and 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
- Critical-thinking, problem-solving, and analytical skills
- Ability to prioritize and manage multiple tasks and caseloads
- Strong verbal and written communication and presentation skills
- Proficiency with Microsoft Office suite (including Excel) and applicable software programs
- In some states, 5 years FWA/SIU/fraud investigations experience may be required (state/contract dependent)
- Certified Professional Compliance Officer (CPCO)
- Certified Fraud Examiner (CFE) and/or Accredited Health Care Fraud Investigator (AHFI)
- Experience with claims processing systems and working knowledge of local, state and federal laws related to health insurance investigations
- Ability to use Microsoft Excel/Access with large data sets and identify trends/patterns
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The Company
What We Do
Molina Healthcare Inc. is dedicated to delivering effective, reliable, and affordable health care to those who need it most. The company focuses on improving the health and well-being of its members and positively impacting the communities it serves. Recognized as a leader in the health insurance category, it provides essential healthcare services to ensure accessible and quality care for its members.
