Job ID 2021379
The 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.
- 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.
High School Diploma / GED (or higher)
- 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, Association
Licensed registered nurse (RN), Licensed practical nurse (LPN) and/or Certified Coder (CPC, CCS, and/or CPMA)
Bachelor’s degree (or higher)
- 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.
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. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Job Type: Full TimePosting Date: 07/24/2023
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