Investigator, SIU( New Mexico)
Company: Molina Healthcare
Location: Albuquerque
Posted on: April 16, 2024
Job Description:
JOB DESCRIPTION
Job Summary
The Special Investigation Unit (SIU) Investigator is responsible
for supporting the prevention, detection, investigation, reporting,
and when appropriate, recovery of money related to health care
fraud, waste, and abuse. -Duties include performing accurate and
reliable medical review audits that may also include coding and
billing reviews. -The SIU Investigator is responsible for reviewing
and analyzing information to draw conclusions on allegations of FWA
and/or may determine appropriateness of care. The SIU Investigator
is also responsible for recognizing and adhering to national and
local coding and billing guidelines in order to maintain coding
accuracy and excellence. -The position also entails producing audit
reports for internal and external review. -The position may also
work with other internal departments, including Compliance,
Corporate Legal Counsel, and Medical Officers in order to achieve
and maintain appropriate anti-fraud oversight.
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Job Duties
- Responsible for developing leads presented to the SIU to assess
and determine whether potential fraud, waste, or abuse is
corroborated by evidence.
- Conducts both preliminary assessments of FWA allegations, and
end to end full 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, and 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 desk top 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 fraud, waste, or abuse.
- Coordinates with various internal customers (e.g., Provider
Services, Contracting and Credentialing, Healthcare Services,
Member Services, Claims) to gather documentation pertinent to
investigations.
- Detects potential health care fraud, waste, and abuse 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
potential fraud, waste, or abuse 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.
- Works may be remote, in office, and on-site travel within the
state of New York as needed.
- 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 MFCU meetings and roundtables on FWA
case development and referral
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JOB QUALIFICATIONS
Required Education
Bachelors degree or Associate's Degree, in criminal justice or
equivalent combination of education and experience
REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES
- 1-3 years of experience, unless otherwise required by state
contract
- Proven investigatory skill; ability to organize, analyze, and
effectively determine risk with corresponding solutions; ability to
remain objective and separate facts from opinions.
- Knowledge of investigative and law enforcement procedures with
emphasis on fraud investigations.
- Knowledge of Managed Care and the Medicaid and Medicare
programs as well as Marketplace.
- Understanding of claim billing codes, medical terminology,
anatomy, and health care delivery systems.
- Understanding of datamining and use of data analytics to detect
fraud, waste, and abuse.
- Proven ability to research and interpret regulatory
requirements.
- Effective interpersonal skills and customer service focus;
ability to interact with individuals at all levels.
- Excellent oral and written communication skills; presentation
skills with ability to create and deliver training, informational
and other types of programs. - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - -
- Advanced skills in Microsoft Office (Word, Excel, PowerPoint,
Outlook), SharePoint and Intra/Internet as well as proficiency with
incorporating/merging documents from various applications.
- Strong logical, analytical, critical thinking and
problem-solving skills.
- Initiative, excellent follow-through, 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, 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
REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:
- Valid driver's license required.
PREFERRED EXPERIENCE:
At least 5 years of experience in FWA or related work.
PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:
- Health Care Anti-Fraud Associate (HCAFA).
- Accredited Health Care Fraud Investigator (AHFI).
- Certified Fraud Examiner (CFE).
-
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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.
#PJCorp
#LI-AC1 Pay Range: $19.64 - $42.55 / HOURLY
*Actual compensation may vary from posting based on geographic
location, work experience, education and/or skill level.
Keywords: Molina Healthcare, Rio Rancho , Investigator, SIU( New Mexico), Other , Albuquerque, New Mexico
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