Investigator, Special Investigative Unit Coding

JOB DESCRIPTION

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.

Job 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.
• 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.

Preferred Qualifications

• 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.