Investigator, Special Investigative Unit Coding (Remote)

Molina Healthcare•Long Beach, CA

3d•Remote

About The Position

Provides support for special investigation unit (SIU) activities related to medical provider coding fraud, waste, and abuse (FWA). Investigates and resolves health care fraud and abuse matters involving medical providers, using informational tips from member benefits and medical records and reviewing post-payment claims. The role independently evaluates claims and related records, determines whether payments were accurate, and completes medical reviews that may support referrals to law enforcement or payment recovery. It also manages case documentation and priorities, prepares clinical summaries, communicates about cases, and supports investigations as required by regulatory agencies.

Requirements

At least 2 years of CPT coding experience in a surgical, hospital, and/or clinic setting, or an equivalent combination of relevant education and experience.
Certification as a Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Professional Medical Auditor (CPMA), or AAPC-certified professional.
Critical-thinking, problem-solving, and analytical skills.
Knowledge of investigative and law enforcement procedures, especially fraud investigations.
Knowledge of managed care and Medicaid, Medicare, and Marketplace programs.
Understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems.
Ability to research and interpret regulatory requirements.
Ability to prioritize and manage multiple tasks and work in a team setting.
Strong verbal and written communication and presentation skills.
Proficiency with Microsoft Office, including Excel, and applicable software programs.
In some states, 5 years of experience in an FWA, SIU, or fraud investigations role may be required, depending on state or contractual requirements.

Nice To Haves

Certified Professional Compliance Officer (CPCO).
Certified Fraud Examiner (CFE) and/or Accredited Health Care Fraud Investigator (AHFI).
Experience working in group health insurance, particularly in claims processing or operations.
Working knowledge of local, state, and federal laws and regulations related to health insurance, investigations, and legal processes, including commercial insurance, Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, and Pharmacy.
Experience with claims processing systems.
Ability to use Microsoft Excel with large quantities of data.
Ability to answer questions, identify trends and patterns, and present findings.

Responsibilities

Independently re-evaluate medical claims and associated records using knowledge of advanced coding, applicable federal and state requirements, and Molina policies.
Review post-payment claims against corresponding medical records to determine payment accuracy.
Manage documents and prioritize caseloads to ensure timely turnaround.
Ensure adherence to applicable state, federal, and internal policies, CPT guidelines, and provider contract requirements.
Prepare clinical summaries following reviews.
Communicate and participate in meetings related to cases.
Complete medical reviews to facilitate referrals to law enforcement or payment recovery.
Support investigation work as required by regulatory agencies.