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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 focused on enhancing the daily functions and strategic initiatives of the Special Investigations Unit (SIU).
Core Responsibilities

• Address all claims of potential fraud, waste, and abuse (FWA). Conduct thorough investigations into fraudulent, wasteful, and abusive practices involving members and providers.

• Evaluate enrollment statistics, medical claims data, 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.

• Execute data analysis, research, and claims review to uncover trends, anomalies, and emerging issues in healthcare fraud, waste, and abuse utilizing advanced fraud detection technology.

• Conduct interviews and investigations to collect further evidence.

• Investigate member identity theft cases through internal reporting mechanisms.

• Regularly communicate with members and providers regarding investigative outcomes, recoveries, and educational insights as necessary.

• Compile, document, and present case findings to the relevant Medicaid Fraud Control Unit or other regulatory bodies.

• Ensure the integrity of documentation for FWA cases. Update the case management system to accurately reflect all communications, evidence, referrals, inquiries, and case developments for record-keeping and legal purposes.

• Foster and maintain strong partnerships with external agencies, including health departments, inspector general offices, drug enforcement agencies, and law enforcement.

• Prepare data requests for external law enforcement as needed.

• Be prepared to travel for provider audits and investigations.

• Draft clear and concise reports, present findings to providers, and engage in the resolution of issues as directed by management. Monitor and report any overpayments resulting from investigations.

• Utilize findings to identify necessary policy changes and determine appropriate actions based on business lines, issue severity, regulatory compliance, and potential exposure.

• Guide team members in generating and evaluating new concepts for expanding investigation opportunities or refining review guidelines for cases.

• Assist SIU management with case evaluations and resolutions.

• Provide mentorship to investigators on investigative methods, tools, and strategies as needed.

• Effectively manage and investigate both complex and straightforward fraud allegations.

• Build 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 participation to ensure training effectiveness and identify any additional training needs.

• Create, modify, and update reports to keep the organization informed of the team's 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 (relevant FWA experience may substitute for educational qualifications).
Experience Requirements

• Minimum of five (5) years of experience in a Managed Care Organization or health insurance company, preferably within an SIU.

• Demonstrated investigative skills; ability to organize, analyze, and effectively assess risk with appropriate solutions; capacity to remain impartial and distinguish facts from opinions.

• Familiarity with investigative and law enforcement protocols, particularly concerning fraud investigations.

• Knowledge of Managed Care and the Medicaid and Medicare programs, as well as the Marketplace.

• Understanding of claim billing codes, medical terminology, anatomy, and healthcare delivery systems.

• Proficiency in data mining and the application of data 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.

• Excellent verbal and written communication skills; ability to create and deliver training and informational programs.

• Advanced proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook), SharePoint, and Internet applications, with experience in document integration from various sources.

• Strong logical, analytical, critical thinking, and problem-solving abilities.

• Initiative, thoroughness, and persistence in obtaining necessary information.

• Basic understanding of audits and corrective actions.

• Ability to manage multiple tasks and operate effectively across different geographical and functional areas.

• Detail-oriented, self-motivated, and 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.

Certifications
  • Certified Professional Coder (CPC)
  • Certified Professional Medical Auditor (CPMA)
Preferred 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.

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