Molina Healthcare-posted about 1 year ago
$45,386 - $106,205/Yr
Full-time
Remote
Insurance Carriers and Related Activities

The SIU Coding Investigator is responsible for investigating and resolving healthcare fraud and abuse by medical providers. This role involves reviewing post-pay claims, managing documentation, and ensuring compliance with state and federal policies, CPT guidelines, and internal requirements. The investigator conducts medical reviews to facilitate referrals to law enforcement or for payment recovery, while also prioritizing a caseload for timely resolution.

  • Investigate and resolve instances of healthcare fraud and abuse by medical providers.
  • Review post-pay claims with corresponding medical records to determine accuracy of claims payments.
  • Review applicable policies, CPT guidelines, and provider contracts.
  • Devise clinical summary post review.
  • Communicate and participate in meetings related to cases.
  • Manage documents and prioritize case load to ensure timely turnaround.
  • Complete medical reviews to facilitate referrals to law enforcement or for payment recovery.
  • High School Diploma / GED (or higher).
  • 3+ years CPT coding experience (surgical, hospital, clinic settings) or 5+ years of experience in a FWA/SIU or Fraud investigations role.
  • Thorough knowledge of PC based software including Microsoft Word and Microsoft Excel.
  • Licensed registered nurse (RN), Licensed practical nurse (LPN) and/or Certified Coder (CPC, CCS, and/or CPMA).
  • Bachelor's degree (or higher).
  • 2+ years of experience working in the group health business, particularly within claims processing or operations.
  • Demonstrated working knowledge of Local, State & Federal laws and regulations pertaining to health insurance, investigations & legal processes.
  • Experience with UNET, Comet, Macess/CSP, or other similar claims processing systems.
  • Demonstrated ability to use MS Excel/Access platforms working with large quantities of data.
  • Competitive benefits and compensation package.
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