Current jobs related to Senior Fraud Investigation Specialist - Long Beach, California - Molina Healthcare

  • Investigator, Coding SIU

    1 week ago

    Long Beach, California, United States Molina Healthcare Full time

    Job Title: Investigator, Coding SIU Job Summary: Molina Healthcare is seeking a skilled Investigator, Coding SIU to join our team. As a key member of our team, you will be responsible for investigating and resolving instances of healthcare fraud and abuse by medical providers. This role requires a strong analytical mind, excellent communication skills, and...

  • Financial Crime Investigator

    2 weeks ago

    Seal Beach, California, United States Workway Full time

    Job Title: Fraud SpecialistWorkway BancForce is a leading national staffing firm that connects qualified job seekers with top employers across the nation. We pride ourselves on offering a candidate-centric approach to help individuals find their next career opportunity.Job Summary:We are seeking an experienced Fraud Specialist to join our team. The...

  • Financial Crime Investigator

    2 days ago

    Seal Beach, California, United States Workway Full time

    Workway BancForce is a leading national staffing firm that places qualified job-seeking candidates across the nation in direct hire, temp-to-hire, and temporary positions across a variety of specialized fields.We pride ourselves in offering a candidate-centric model to assist job seekers in finding their next career opportunity.We are seeking an experienced...

  • Senior Civil Litigation Attorney

    4 weeks ago

    Long Beach, California, United States gpac Full time

    Job Title: Senior Civil Litigation AttorneyGPAC is seeking a talented Senior Civil Litigation Attorney to join our team in Southern California or Northern California/Bay Area. This is an excellent opportunity for a motivated attorney to work on both insurance bad faith and general liability matters in a collaborative, forward-thinking environment.Key...

  • Senior Environmental Engineer

    3 days ago

    Long Beach, California, United States AECOM Full time

    AECOM is seeking a Senior Environmental Engineer to join our Southern California Site Investigation and Remediation team.The ideal candidate will have 6 years of experience in environmental engineering consulting or demonstrated equivalency of experience and education.Responsibilities may include:Providing specialized technical input to studies and design in...

  • Loss Prevention Manager

    4 weeks ago

    Long Beach, California, United States Custom Goods LLC Full time

    Job Title: Loss Prevention ManagerCustom Goods, LLC is seeking a highly skilled Loss Prevention Manager to join our team. As a key member of our organization, you will be responsible for developing and implementing strategies to minimize the risk of theft, fraud, and other security breaches within the company.Key Responsibilities:Design and implement loss...

  • Loss Prevention Manager

    3 weeks ago

    Long Beach, California, United States Custom Goods LLC Full time

    Job Title: Loss Prevention ManagerAt Custom Goods LLC, we are seeking a highly skilled Loss Prevention Manager to join our team. This role is responsible for developing and implementing strategies to minimize the risk of theft, fraud, and other security breaches within the organization.Key Responsibilities:Develop and implement loss prevention strategies,...

  • Senior IT Infrastructure Specialist

    1 week ago

    Long Beach, California, United States MW Partners LLC Full time

    Job Title: Senior IT Infrastructure SpecialistWe are seeking a highly skilled Senior IT Infrastructure Specialist to join our team at MW Partners LLC. As a key member of our IT team, you will be responsible for designing, implementing, and operating various platform and operating system environments.Key Responsibilities:Design and implement platform and...

  • Senior Technical Specialist

    7 days ago

    Newport Beach, California, United States Simpson Gumpertz & Heger Full time

    We are seeking a highly skilled and experienced Senior Technical Specialist to join our team at Simpson Gumpertz & Heger. As a Senior Technical Specialist, you will act as a project manager for small to medium-sized projects, managing challenging single major projects or multiple projects requiring supervision of several staff and client relationships.Key...

  • Civil Litigation Attorney

    3 days ago

    Long Beach, California, United States gpac Full time

    Job Title: Civil Litigation AttorneyJob Summary:GPAC is seeking a talented Civil Litigation Attorney to join their team in a dynamic civil litigation practice. This is an excellent opportunity for a motivated attorney to work on both insurance bad faith and general liability matters in a collaborative environment.Key Responsibilities:Manage a diverse...

  • Midlevel Associate Attorney

    4 weeks ago

    Long Beach, California, United States Gpac Full time

    Job Title: Midlevel Associate AttorneyWe are seeking a talented Midlevel Associate Attorney to join our dynamic civil litigation practice in Southern California or Northern California/Bay Area. This is an excellent opportunity for a motivated attorney to work on both insurance bad faith and general liability matters in a collaborative, forward-thinking...

  • Senior Environmental Engineer

    1 week ago

    Long Beach, California, United States AECOM Full time

    About the RoleAECOM is seeking a highly skilled Senior Environmental Engineer to join our Southern California Site Investigation and Remediation team. As a key member of our team, you will play a critical role in delivering high-quality projects and promoting growth.Key ResponsibilitiesProvide technical expertise and guidance to the team on remediation...

  • Senior Manufacturing Engineer

    3 days ago

    Long Beach, California, United States Rocket Lab Full time

    About Rocket LabRocket Lab is a global leader in launch and space systems. Our mission is to unlock the potential of space to improve life on Earth. We design, build, and launch advanced rockets and satellites that enable scientific exploration, Earth observation, and missions to combat climate change, national security, and exciting new technology...

  • Senior Procurement Specialist/Global Sourcing

    2 weeks ago

    Long Beach, California, United States Singer Vehicle Design Full time

    Job Title: Senior Procurement Specialist/Global SourcingWe are seeking a highly skilled Senior Procurement Specialist/Global Sourcing to join our team at Singer Vehicle Design. As a key member of our supply chain team, you will be responsible for developing commodity strategies, sourcing and qualifying vendors, negotiating pricing, and placing purchase...

  • Senior Environmental Engineer

    2 weeks ago

    Long Beach, California, United States AECOM Full time

    Job Title: Senior Environmental Engineer - Remediation ExpertAECOM is seeking a highly skilled Senior Environmental Engineer to join our Southern California Site Investigation and Remediation team. As a key member of our team, you will be responsible for delivering high-quality technical services to our clients.Responsibilities:Provide technical expertise in...

  • Housing Specialist

    2 weeks ago

    Long Beach, California, United States City of Long Beach, CA Full time

    Job Title: Housing SpecialistJoin the City of Long Beach, CA team as a Housing Specialist and contribute to the development and implementation of housing programs and services that support low-income individuals and families.Job Summary:The Housing Specialist will work under general supervision to perform complex activities in the Federal Section 8 Housing...

  • Senior Integration Specialist

    3 days ago

    Long Beach, California, United States Vast Full time

    Job SummaryVast is seeking a highly skilled Senior Integration Specialist to support vehicle integration operations, including the build of Avionics, Propulsion, and Structures systems for our space station, Haven-1. This is a full-time, non-exempt position in our Long Beach location.Key Responsibilities Assemble, install, and test flight hardware Use...

  • Asset Protection Professional

    6 days ago

    Huntington Beach, California, United States Home Depot Full time

    Job Title: Asset Protection SpecialistAt Home Depot, we're committed to providing a safe and secure shopping environment for our customers. As an Asset Protection Specialist, you'll play a critical role in preventing financial loss caused by theft and fraud.Key Responsibilities:Prevent financial loss by identifying and investigating incidents of theft and...

  • Senior Legal Counsel

    2 weeks ago

    Long Beach, California, United States SCAN Health Plan Full time

    About SCAN Health PlanSCAN Health Plan is a not-for-profit organization dedicated to providing high-quality healthcare services to older adults in the United States. With over 40 years of experience, SCAN has established itself as a leading expert in senior healthcare, serving over 285,000 members in California, Arizona, Nevada, and Texas.The JobThe Legal...

  • Senior Quality Assurance Specialist

    4 weeks ago

    Long Beach, California, United States BeautyHealth Full time

    About UsBeautyHealth is a global leader in the beauty and health industry, dedicated to delivering innovative products and experiences that enhance our customers' lives. We're a company that values excellence, innovation, and teamwork, and we're looking for talented individuals to join our team.Job Description:The Senior Quality Specialist will play a...

Senior Fraud Investigation Specialist

2 months ago

Long Beach, California, United States Molina Healthcare Full time

Job Overview

Position Summary

The Senior Fraud Investigation Specialist role is primarily tasked with facilitating the daily functions and strategic initiatives of the Special Investigations Unit (SIU).


Core Competencies

  • Address all reports of potential fraud, waste, and abuse (FWA). Execute thorough investigations into fraudulent, wasteful, and abusive practices involving members and providers.
  • Examine enrollment data, medical claims, contractual agreements, financial documentation, and claims history to identify FWA and discern potential trends. Implement regulatory and contractual standards alongside internal policies throughout the investigative process.
  • Conduct data analysis and review claims to uncover trends, anomalies, and emerging issues related to healthcare fraud, waste, and abuse utilizing fraud detection technology.
  • Carry out investigations and interviews to collect supplementary evidence.
  • Investigate member identity theft cases through internal reporting channels.
  • Maintain regular communication with members and providers regarding investigative outcomes, recoveries, and educational insights as appropriate.
  • Compile, document, and present case findings to relevant regulatory bodies or Medicaid Fraud Control Units.
  • Ensure the integrity of documentation for FWA cases. Update case management systems to accurately reflect all communications, evidence, referrals, inquiries, and case developments for record-keeping and legal purposes.
  • Establish and nurture strong partnerships with external agencies, including health departments, inspector general offices, and law enforcement.
  • Prepare data requests for external law enforcement as necessary.
  • Willingness to travel for onsite audits and investigations.
  • Draft clear and concise reports, present findings to providers, and engage in negotiated resolutions under management direction. Monitor and report any overpayments resulting from investigations.
  • Utilize findings to identify areas needing policy adjustments and recommend appropriate actions based on business lines, issue severity, compliance requirements, and organizational exposure.
  • Guide team members in generating and evaluating new concepts for enhancing investigation opportunities or refining review protocols.
  • Assist SIU Management in reviewing and resolving cases.
  • Provide mentorship to investigators on investigative methods, tools, and strategies as needed.
  • Effectively manage and investigate both complex and straightforward fraud allegations.
  • Develop and sustain relationships with key business units within specific product lines and geographic areas.
  • Offer direction and support to the investigative team, especially in the absence of the SIU Manager.
  • Monitor team training effectiveness and identify additional training needs.
  • Create, modify, and update reports to inform the organization about team progress.
  • Perform additional duties as assigned.

Qualifications

Education Requirements

  • Associate's or Bachelor's degree in Health Information Management, Healthcare Administration, Finance, Criminal Justice, Law Enforcement, or a related field (applicable FWA experience may substitute for educational qualifications).

Experience Requirements

  • A minimum of five (5) years of experience in a Managed Care Organization or health insurance setting (preferably within an SIU).
  • Demonstrated investigatory skills; ability to organize, analyze, and effectively assess risk with appropriate solutions; ability to maintain objectivity and distinguish facts from opinions.
  • Familiarity with investigative and law enforcement protocols, particularly in fraud investigations.
  • Knowledge of Managed Care, Medicaid, Medicare programs, and Marketplace.
  • Understanding of claim billing codes, medical terminology, anatomy, and healthcare delivery systems.
  • Proficiency in data mining and analytics to detect fraud, waste, and abuse.
  • Proven ability to research and interpret regulatory requirements.
  • Strong interpersonal skills and a customer service orientation; ability to engage with individuals at all organizational levels.
  • Exceptional oral and written communication skills; adept at creating and delivering training and informational programs.
  • Advanced proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook), SharePoint, and internet applications, including document integration from various sources.
  • Strong logical, analytical, critical thinking, and problem-solving abilities.
  • Self-motivated with a strong initiative, persistence in gathering necessary information.
  • Basic understanding of audits and corrective actions.
  • Ability to manage multiple tasks and operate effectively across various geographic and functional areas.
  • Detail-oriented, self-driven, capable of meeting tight deadlines.
  • Ability to set realistic, motivating goals and objectives, track progress, and adapt to changing priorities.
  • Energetic, forward-thinking, with high ethical standards and a professional demeanor.
  • Collaborative and team-oriented.

Licenses and Certifications

  • Accredited Health Care Fraud Investigator (AHFI) certification required.

Preferred Licenses and Certifications

  • Certified Fraud Examiner (CFE).
  • Certified Professional Coder (CPC).
  • Certificates/designations and/or advanced training in healthcare fraud and abuse investigations.
  • Certified Health Care Anti-Fraud Associate (HCAFA).

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