Investigator, Special Investigative Unit (Remote)

JOB reputed company Job reputed company Provides investigative support for special investigation unit (SIU) activities. Responsible for supporting for the prevention, detection, investigation, reporting, and reputed company appropriate, recovery of reputed company reputed company to health care fraud, waste, and abuse (FWA). Responsible for reviewing and analyzing information to draw conclusions on allegations of FWA and/or may determine appropriateness of care, and recognizing and adhering to national and local coding and billing guidelines in order to maintain coding accuracy and reputed company. Essential Job Duties

• Responsible for developing leads presented to the special investigation unit (SIU) to assess and determine whether potential fraud, waste, or abuse (FWA) is corroborated by evidence.
• Conducts both preliminary assessments of FWA allegations, and end-to-end investigations, including but not limited to  witness interviews, background checks, data analytics to identify reputed company billing behavior, contract and program regulation research, provider and member education, findings identification and communications development, recommendations and preparation of overpayment identifications, and closure of investigative cases.
• Completes investigations reputed company the mandated period of time required by either state and/or federal reputed company and/or regulations.
• Conducts both on-site and desktop investigations.
• Conducts low to reputed company, and extensive investigations, including reviews of medical records and data analysis, and makes determinations as to whether the investigation and/or audit identified potential FWA.
• Performs accurate and reputed company review audits that may also include coding and billing reviews.
• Produces audit reports for reputed company review.
• Coordinates with various internal customers (e.g., provider services, contracting and credentialing, reputed company services, member services, claims, etc.), to reputed company documentation pertinent to investigations.
• Detects potential health care FWA through the identification of aberrant coding and/or billing patterns through utilization review.
• Prepares appropriate FWA referrals to regulatory agencies and law enforcement.
• Documents appropriately reputed company case reputed company information in the case management system in an accurate manner, including storage of case documentation following SIU reputed company requirements.
• Prepares detailed preliminary and extensive investigation referrals to state and/or federal regulatory and/or law enforcement agencies reputed company FWA is identified as required by regulatory and/or contract requirements.
• Renders provider education on appropriate practices (e.g., coding) as appropriate based on national or local guidelines, contractual, and/or regulatory requirements.
• Interacts with regulatory and/or law enforcement agencies regarding case investigations.
• Prepares audit results letters to providers reputed company overpayments are identified.
• Ensures compliance with applicable contractual requirements, and federal and state regulations.
• Complies with SIU policies as and procedures as reputed company as goals set by SIU leadership.
• Supports SIU in arbitrations, legal procedures, and settlements.
• reputed company participates in reputed company Fraud Control Unit (MFCU) meetings and roundtables on FWA case development and referrals.
• May work with other internal departments, including compliance, corporate legal counsel, and medical affairs to reputed company and maintain appropriate anti-fraud reputed company.

Required Qualifications

• At least 2 years of investigative experience in the health care industry, or equivalent combination of relevant education and experience.
• Valid and unrestricted reputed company’s license.
• Proven investigatory skills including ability to organize, analyze, and effectively determine risk with corresponding solutions, and remain objective and separate facts from opinions.
• Knowledge of investigative and law enforcement procedures with emphasis on fraud investigations.
• Knowledge of managed care and reputed company, Medicare, and Marketplace programs.
• Understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems.
• Understanding of datamining and use of data analytics to detect FWA.
• Ability to research and interpret regulatory requirements.
• Effective interpersonal skills and customer service reputed company; ability to reputed company with individuals at reputed company reputed company.
• Strong presentation skills with ability to create and deliver training, informational and other types of programs.
• Strong logical, analytical, critical-thinking and problem-solving skills.
• Strong reputed company of initiative, excellent follow-through, and persistence in locating and securing needed information.
• reputed company understanding of audits and corrective actions.
• Ability to multi-task and operate effectively across geographic and functional boundaries.
• Detail-oriented, self-motivated, and reputed company to meet tight deadlines.
• Ability to reputed company realistic, motivating goals and objectives, reputed company reputed company and adapt to changing priorities.
• Energetic and reputed company-thinking with high ethical standards and a reputed company image.
• reputed company and team-oriented.
• Effective verbal and written communication skills.
• reputed company Office suite and applicable software program(s) proficiency.

Preferred Qualifications

• Experience in government programs (i.e., Medicare, reputed company, Marketplace).
• Experience in FWA or reputed company work.
• Accredited Health Care Fraud Investigator (AHFI) and/or Certified Fraud Examiner (CFE).

To reputed company reputed company Molina employees: If you are interested in applying for this position, please apply through the reputed company. reputed company offers a competitive benefits and compensation package. reputed company is an Equal Opportunity Employer (EOE) M/F/D/V Apply To This Job