Fraud Investigation Specialist, SIU

1 week ago

Long Beach, California, United States Molina Healthcare Full time
Job Overview

The Special Investigation Unit (SIU) Investigator plays a crucial role in the identification, prevention, and investigation of healthcare fraud, waste, and abuse. This position is tasked with conducting thorough medical review audits, which may encompass coding and billing assessments. The SIU Investigator is responsible for evaluating and interpreting data to draw informed conclusions regarding allegations of fraud, waste, and abuse, while ensuring adherence to national and local coding standards to maintain accuracy and integrity in coding practices. Additionally, the role involves generating detailed audit reports for both internal and external stakeholders.

Key Responsibilities
  • Develop leads presented to the SIU to evaluate and confirm potential fraud, waste, or abuse through evidence-based assessments.
  • Conduct preliminary evaluations of fraud allegations and comprehensive investigations, including witness interviews, background checks, and data analysis to identify unusual billing patterns.
  • Complete investigations within the timeframes mandated by relevant state and federal regulations.
  • Perform both on-site and remote investigations as necessary.
  • Engage in extensive reviews of medical records and data to determine the presence of fraud, waste, or abuse.
  • Collaborate with various internal departments to gather essential documentation for investigations.
  • Identify potential healthcare fraud through the analysis of coding and billing patterns.
  • Prepare appropriate referrals to regulatory bodies and law enforcement when necessary.
  • Document all case-related information accurately in the case management system, ensuring compliance with SIU requirements.
  • Provide education to providers on best practices in coding and billing according to established guidelines.
  • Engage with regulatory and law enforcement agencies regarding ongoing investigations.
  • Draft audit result letters to providers when overpayments are detected.
  • Work may involve remote, in-office, and on-site travel as required.
  • Ensure compliance with applicable contractual obligations and federal and state regulations.
  • Adhere to SIU policies and procedures, as well as objectives set by SIU leadership.
  • Support SIU in legal proceedings and settlements.
  • Participate actively in meetings focused on fraud case development and referrals.
Qualifications

Education
Bachelor's degree or Associate's Degree in criminal justice or a related field, or an equivalent combination of education and experience.

Experience and Skills
  • 1-3 years of relevant experience, unless otherwise specified by state contract.
  • Demonstrated investigative skills with the ability to analyze and assess risks effectively.
  • Familiarity with investigative procedures, particularly in fraud investigations.
  • Knowledge of Managed Care, Medicaid, Medicare, and Marketplace programs.
  • Understanding of medical billing codes, terminology, and healthcare delivery systems.
  • Proficient in data mining and analytics for fraud detection.
  • Ability to interpret regulatory requirements accurately.
  • Strong interpersonal skills with a focus on customer service.
  • Excellent communication skills, both oral and written, with the ability to deliver training and presentations.
  • Advanced proficiency in Microsoft Office Suite and other relevant software.
  • Strong analytical and problem-solving abilities.
  • Detail-oriented and self-motivated, capable of meeting tight deadlines.
  • Ability to set realistic goals and adapt to changing priorities.
  • High ethical standards and a professional demeanor.
  • Team-oriented with a collaborative approach.
Licenses and Certifications
  • Valid driver's license is required.
Preferred Experience
At least 5 years of experience in fraud investigation or a related field.

Preferred Certifications
  • Health Care Anti-Fraud Associate (HCAFA).
  • Accredited Health Care Fraud Investigator (AHFI).
  • Certified Fraud Examiner (CFE).

Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

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