Investigator, Special Investigative Unit (Remote)

Molina Healthcare•Long Beach, TX

1d•Remote

About The Position

Provides investigative support for special investigation unit (SIU) activities, including the prevention, detection, investigation, reporting, and, when appropriate, recovery of money related to health care fraud, waste, and abuse (FWA). Reviews and analyzes information to draw conclusions about FWA allegations and may determine appropriateness of care, while recognizing and adhering to national and local coding and billing guidelines to maintain accuracy. The role develops and conducts preliminary and end-to-end investigations, including interviews, background checks, data analytics, regulatory and contract research, provider and member education, findings and recommendations, overpayment identification, and case closure. Investigations may be on-site or desktop and can include medical-record reviews, data analysis, coding and billing audits, audit reporting, referrals to regulatory agencies or law enforcement, and interaction with agencies. The Investigator documents cases, meets mandated investigation timeframes, supports legal proceedings and settlements, and helps ensure compliance with contractual requirements and federal and state regulations.

Requirements

At least 2 years of investigative experience in the health care industry, or an equivalent combination of relevant education and experience.
Valid and unrestricted driver’s license.
Investigatory skills, including the ability to organize and analyze information, assess risk and solutions, remain objective, and separate facts from opinions.
Knowledge of investigative and law enforcement procedures, with emphasis on 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.
Understanding of data mining and data analytics used to detect FWA.
Ability to research and interpret regulatory requirements.
Effective interpersonal skills and customer-service focus, with the ability to interact with individuals at all levels.
Presentation skills and the ability to create and deliver training, informational, and other programs.
Strong logical, analytical, critical-thinking, and problem-solving skills.
Initiative, follow-through, and persistence in locating and securing information.
Fundamental understanding of audits and corrective actions.
Ability to multitask and work effectively across geographic and functional boundaries.
Detail-oriented, self-motivated, and able to meet tight deadlines.
Ability to develop realistic and motivating goals and objectives, track progress, and adapt to changing priorities.
Energetic and forward-thinking, with high ethical standards and a professional image.
Collaborative and team-oriented approach.
Effective verbal and written communication skills.
Proficiency with Microsoft Office suite and applicable software programs.

Nice To Haves

Experience in government programs such as Medicare, Medicaid, or Marketplace.
Experience in FWA or related work.
Accredited Health Care Fraud Investigator (AHFI) and/or Certified Fraud Examiner (CFE).

Responsibilities

Develop leads presented to the SIU and assess whether evidence corroborates potential fraud, waste, or abuse.
Conduct preliminary assessments and end-to-end investigations, including witness interviews, background checks, data analytics, contract and program regulation research, provider and member education, findings communications, recommendations, overpayment identification, and case closure.
Complete investigations within timeframes mandated by state or federal contracts and regulations.
Conduct on-site and desktop investigations.
Conduct low-to-medium and extensive investigations, including medical-record reviews and data analysis, and determine whether potential FWA was identified.
Perform medical review audits, which may include coding and billing reviews.
Produce audit reports for internal and external review.
Coordinate with internal customers to gather documentation relevant to investigations.
Detect potential health care FWA by identifying aberrant coding or billing patterns through utilization review.
Prepare FWA referrals to regulatory agencies and law enforcement, including detailed preliminary and extensive investigation referrals when required.
Document case information accurately in the case management system and store case documentation according to SIU requirements.
Provide provider education on appropriate practices, including coding, as appropriate under national or local guidelines and contractual or regulatory requirements.
Interact with regulatory and law enforcement agencies regarding investigations.
Prepare provider audit-results letters when overpayments are identified.
Ensure compliance with contractual requirements and federal and state regulations, and follow SIU policies, procedures, and leadership goals.
Support SIU activities in arbitrations, legal procedures, and settlements.
Participate in Medicaid Fraud Control Unit meetings and roundtables on FWA case development and referrals.
Work with internal departments, including compliance, corporate legal counsel, and medical affairs, to maintain appropriate anti-fraud oversight.