JOB DESCRIPTIONJob SummaryThe SIU Coding Investigator is responsible for investigating and resolving instances of healthcare fraud and abuse by medical providers. This position uses information from a tip, member benefits, and medical records to document relevant findings of a post pay clinical review. This position manages documents and prioritizes case load to ensure timely turn around. This position ensures adherence to state and federal policies, CPT guidelines, internal policies, and contract requirements. This position completes a medical review to facilitate a referral to law enforcement or for payment recovery.KNOWLEDGE/SKILLS/ABILITIES
Reviews post pay claims with corresponding medical records to determine accuracy of claims payments.
Review of applicable policies, CPT guidelines, and provider contracts.
Devise clinical summary post review.
Communicate and participate in meetings related to cases.
Critical thinking, problem solving and analytical skills.
Ability to prioritize and manage multiple tasks.
Proven ability to work in a team setting.
Excellent oral and written communication skills and presentation skills.
JOB QUALIFICATIONSRequired EducationHigh School Diploma / GED (or higher)Required Experience
3+ years CPT coding experience (surgical, hospital, clinic settings) or 5+ years of experience working in a FWA / SIU or Fraud investigations role for New Jersey/New York location
Thorough knowledge of PC based software including Microsoft Word (edit/save documents) and Microsoft Excel (edit/save spreadsheets, sort/filter)
Required License, Certification, AssociationLicensed registered nurse (RN), Licensed practical nurse (LPN) and/or Certified Coder (CPC, CCS, and/or CPMA)Preferred EducationBachelor's degree (or higher)Preferred Experience
2+ years of experience working in the group health business preferred, particularly within claims processing or operations.
A demonstrated working knowledge of Local, State & Federal laws and regulations pertaining to health insurance, investigations & legal processes (Commercial insurance, Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, etc.)
Experience with UNET, Comet, Macess/CSP, or other similar claims processing systems.
Demonstrated ability to use MS Excel/Access platforms working with large quantities of data to answer questions or identify trends and patterns, and the ability to present those findings.
Preferred License, Certification, Association
AAPC Certified Medical CPC, CPMA, CPCO or similar specialist preferred
Certified Fraud Examiner and/or AHFI professional designations preferred
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: $21.82 - $51.06 / HOURLYActual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
