Special Investigation Unit (SIU) Investigator - Remote

Overview

The Special Investigation Unit (SIU) Investigator is responsible for supporting the prevention, detection, investigation, reporting, and when appropriate, recovery of money related to health care fraud, waste, and abuse. Duties include performing accurate and reliable medical review audits that may also include coding and billing reviews. The SIU Investigator is responsible for reviewing and analyzing information to draw conclusions on allegations of FWA and/or may determine appropriateness of care. The SIU Investigator is also responsible for recognizing and adhering to national and local coding and billing guidelines in order to maintain coding accuracy and excellence. The position also entails producing audit reports for internal and external review. The position may also work with other internal departments, including Compliance, Corporate Legal Counsel, and Medical Officers in order to achieve and maintain appropriate anti-fraud oversight.

In Short

• Responsible for developing leads presented to the SIU to assess and determine whether potential fraud, waste, or abuse is corroborated by evidence.
• Conducts both preliminary assessments of FWA allegations, and end to end full investigations.
• Completes investigations within the mandated period of time required by either state and/or federal contracts and/or regulations.
• Conducts both on-site and desk top investigations.
• Coordinates with various internal customers to gather documentation pertinent to investigations.
• Detects potential health care fraud, waste, and abuse through the identification of aberrant coding and/or billing patterns.
• Prepares appropriate FWA referrals to regulatory agencies and law enforcement.
• Documents appropriately all case related information in the case management system.
• Renders provider education on appropriate practices based on national or local guidelines.
• Interacts with regulatory and/or law enforcement agencies regarding case investigations.

Requirements

• Bachelors degree or Associate’s Degree in criminal justice or equivalent combination of education and experience.
• 1-3 years of experience in FWA or related work.
• Proven investigatory skill; ability to organize, analyze, and effectively determine risk.
• Knowledge of investigative and law enforcement procedures with emphasis on fraud investigations.
• Understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems.
• Effective interpersonal skills and customer service focus.
• Excellent oral and written communication skills.
• Advanced skills in Microsoft Office.
• Strong logical, analytical, critical thinking and problem-solving skills.
• Detail-oriented, self-motivated, able to meet tight deadlines.

Benefits

• Molina Healthcare offers a competitive benefits and compensation package.
• Equal Opportunity Employer (EOE) M/F/D/V.