Investigator, Special Investigative Unit-Must reside in KY

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 reviews and analyzes information to draw conclusions on allegations of FWA and / or may determine appropriateness of care. The SIU Investigator recognizes and adheres to national and local coding and billing guidelines to maintain coding accuracy. The position also entails producing audit reports for internal and external review. The position may work with other internal departments, including Compliance, Corporate Legal Counsel, and Medical Officers to achieve and maintain appropriate anti-fraud oversight.

Responsibilities

• Develops leads presented to the SIU to assess and determine whether potential fraud, waste, or abuse is corroborated by evidence.
• Conducts preliminary assessments of FWA allegations and end-to-end investigations, including witness interviews, background checks, data analytics to identify outlier billing behavior, contract and program regulation research, provider and member education, findings identification and communications development, and recommendations and preparation of overpayment identifications and closure of investigative cases.
• Completes investigations within mandated timeframes according to state and / or federal contracts and / or regulations.
• Conducts on-site and desk-top investigations.
• Conducts low to medium and extensive investigations, including reviews of medical records and data analysis, and determines whether there is potential fraud, waste, or abuse.
• Coordinates with internal teams (Provider Services, Contracting and Credentialing, Healthcare Services, Member Services, Claims) to gather documentation.
• Detects potential health care fraud, waste, and abuse through aberrant coding and / or billing patterns identified via utilization review.
• Prepares appropriate FWA referrals to regulatory agencies and law enforcement.
• Documents case information in the case management system, stores documentation per SIU requirements, and prepares detailed referral documents for state / federal agencies when needed.
• Provides provider education on appropriate practices (e.g., coding) as appropriate based on guidelines and regulatory requirements.
• Interacts with regulatory and / or law enforcement agencies regarding case investigations.
• Prepares audit results letters to providers when overpayments are identified.
• Travel may be required; work may be remote, in office, or on-site within New York State.
• Ensures compliance with contractual requirements and federal / state regulations.
• Complies with SIU policies and procedures and SIU leadership goals.
• Supports SIU in arbitrations, legal proceedings, and settlements.
• Participates in MFCU meetings and roundtables on FWA case development and referrals.

Qualifications

Required Education

Bachelors degree or Associate's Degree, in criminal justice or equivalent combination of education and experience

Required Experience / Knowledge, Skills & Abilities

Licenses and Certifications

Preferred Experience

At least 5 years of experience in FWA or related work.

Preferred Licenses / Certifications

To all current Molina employees : If you are interested in applying for this position, please apply through the intranet job listing.

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

Pay Range : $20.73 - $42.55 / HOURLY

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