Investigator, Special Investigative Unit Coding (Remote)
Investigator, Special Investigative Unit Coding
Molina Healthcare Job ID: 2037329
About the role
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.
Responsibilities
- 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.
Requirements
- 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.
Qualifications
- 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.
Skills
- 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.
Benefits
Molina Healthcare offers a competitive benefits and compensation package.
Pay
Pay Range: $19.64 - $42.55 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
Company Information
Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others.
Contact Information
Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.