• 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.
• 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).
• 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
Skills Required
- At least 2 years of CPT coding experience in a surgical, hospital, or clinic setting, or equivalent education and experience
- CPC, CCS, CPMA, or AAPC certification
- Critical-thinking, problem-solving, and analytical skills
- Knowledge of investigative and law enforcement procedures, especially fraud investigations
- Knowledge of managed care, Medicaid, Medicare, and Marketplace programs
- Knowledge of claim billing codes, medical terminology, anatomy, and healthcare delivery systems
- Ability to research and interpret regulatory requirements
- Ability to prioritize and manage multiple tasks
- Teamwork, verbal communication, written communication, and presentation skills
- Proficiency with Microsoft Office, including Excel, and applicable software programs
- In some states, 5 years of FWA, SIU, or fraud investigations experience may be required
- CPCO, CFE, and/or AHFI certification
- Experience in group health insurance claims processing or operations
- Knowledge of health insurance laws, regulations, investigations, and legal processes
- Experience with claims processing systems
- Experience using Excel with large quantities of data
- Ability to identify trends and patterns and present findings
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.
