JOB DESCRIPTION
Leads and manages team responsible for special investigation unit (SIU) activities, specifically the prevention and detection of violation of applicable laws and regulations. Responsible to protect the business from liability of fraudulent or abusive practices, and ensure the business understands and complies with applicable laws and regulations pertaining to the health care environment. Accountable for oversight, follow-up and resolution of investigations.
Essential Job Duties
• Provides oversight and review of the special investigation until (SIU) referral intake and investigation process, and provides guidance and direction to team on case investigation steps/actions.
• Collaborates with leadership to maintain and revise policies and procedures, fraud, waste, and abuse (FWA) plans, annual audit work plans - including department guidance memos, and educational materials.
• Identifies opportunities for improvement through the audit process and provides recommendations for system enhancements in order to augment investigative outcomes and performance.
• Accurately tracks, reports, and follows-up on overpayments and recoveries.
• Leads business requirement process and reporting to ensure proper and timely notification of case activity to the appropriate regulatory and/or law enforcement agency.
Job Requirements
• At least 7 years of experience in special investigations, law enforcement, and/or experience in a regulatory environment, or equivalent combination of relevant education and experience.
• At least 1 year of management/leadership experience.
• Strong interpersonal skills.
• Strong analytical and critical-thinking abilities.
• Organizational and time-management skills.
• Experience with investigative case management system.
• Strong verbal and written communication skills.
• Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications
• Health Care Anti-Fraud Associate (HCAFA), Accredited Health Care Fraud Investigator (AHFI) and/or Certified Fraud Examiner (CFE).
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
Skills Required
- At least 7 years of experience in special investigations, law enforcement, and/or regulatory environment or equivalent combination of relevant education and experience.
- At least 1 year of management/leadership experience.
- Experience with investigative case management system.
- Microsoft Office suite/applicable software program(s) proficiency.
- Strong interpersonal skills.
- Strong analytical and critical-thinking abilities.
- Organizational and time-management skills.
- Strong verbal and written communication skills.
- Health Care Anti-Fraud Associate (HCAFA), Accredited Health Care Fraud Investigator (AHFI) and/or Certified Fraud Examiner (CFE).
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.
