Investigator, Special Investigative Unit

JOB DESCRIPTION Job Summary

Provides investigative support for special investigation unit (SIU) activities. Responsible for supporting for the prevention, detection, investigation, reporting, and when appropriate, recovery of money related 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 excellence.

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 outlier 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 within the mandated period of time required by either state and/or federal contracts and/or regulations.
  • Conducts both on-site and desktop investigations.
  • Conducts low to medium, 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 reliable medical review audits that may also include coding and billing reviews.
  • Produces audit reports for internal and external review.
  • Coordinates with various internal customers (e.g., provider services, contracting and credentialing, healthcare services, member services, claims, etc.), to gather 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 all case related information in the case management system in an accurate manner, including storage of case documentation following SIU related requirements.
  • Prepares detailed preliminary and extensive investigation referrals to state and/or federal regulatory and/or law enforcement agencies when 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 when overpayments are identified.
  • Ensures compliance with applicable contractual requirements, and federal and state regulations.
  • Complies with SIU policies as and procedures as well as goals set by SIU leadership.
  • Supports SIU in arbitrations, legal procedures, and settlements.
  • Actively participates in Medicaid 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 achieve and maintain appropriate anti-fraud oversight.

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 driver’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 Medicaid, 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 focus; ability to interact with individuals at all levels.
  • 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 sense of initiative, excellent follow-through, and persistence in locating and securing needed information.
  • Fundamental understanding of audits and corrective actions.
  • Ability to multi-task and operate effectively across geographic and functional boundaries.
  • Detail-oriented, self-motivated, and able to meet tight deadlines.
  • Ability to develop realistic, motivating goals and objectives, track progress and adapt to changing priorities.
  • Energetic and forward-thinking with high ethical standards and a professional image.

• Collaborative and team-oriented.

• Effective verbal and written communication skills.
  • Microsoft Office suite and applicable software program(s) proficiency.

Preferred Qualifications

• Experience in government programs (i.e., Medicare, Medicaid, Marketplace).

• Experience in FWA or related work.

• Accredited Health Care Fraud Investigator (AHFI) and/or Certified Fraud Examiner (CFE).

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

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

Originally posted on Himalayas