Investigator, Special Investigative Unit Coding (Remote)
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.
- 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.
- 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.