**JOB DESCRIPTION**
**Job Summary**
The SIU Coding Investigator is responsible for investigating and resolving instances of healthcare fraud and abuse by medical providers. This position uses information from a tip, member benefits, and medical records to document relevant findings of a post pay clinical review. This position manages documents and prioritizes case load to ensure timely turn around. This position ensures adherence to state and federal policies, CPT guidelines, internal policies, and contract requirements. This position completes a medical review to facilitate a referral to law enforcement or for payment recovery.
**KNOWLEDGE/SKILLS/ABILITIES**
+ Reviews post pay claims with corresponding medical records to determine accuracy of claims payments.
+ Review of applicable policies, CPT guidelines, and provider contracts.
+ Devise clinical summary post review.
+ Communicate and participate in meetings related to cases.
+ Critical thinking, problem solving and analytical skills.
+ Ability to prioritize and manage multiple tasks.
+ Proven ability to work in a team setting.
+ Ability to analyze data to identify FWA Trends
+ Excellent oral and written communication skills and presentation skills.
**JOB QUALIFICATIONS**
**Required Education**
High School Diploma / GED (or higher)
**Required Experience**
+ 3+ years CPT coding experience (surgical, hospital, clinic settings) or 5+ years of experience working in a FWA / SIU or Fraud investigations role for New Jersey/New York location
+ Thorough knowledge of PC based software including Microsoft Word (edit/save documents) and Microsoft Excel (edit/save spreadsheets, sort/filter)
**Required License, Certification, Association**
Certified Coder (CPC, CCS, and/or CPMA)
**Preferred Education**
Bachelor's degree (or higher)
**Preferred Experience**
+ 2+ years of experience working in the group health business preferred, particularly within claims processing or operations.
+ A demonstrated working knowledge of Local, State & Federal laws and regulations pertaining to health insurance, investigations & legal processes (Commercial insurance, Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, etc.)
+ 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 to answer questions or identify trends and patterns, and the ability to present those findings.
**Preferred License, Certification, Association**
+ AAPC Certified Medical CPC, CPMA, CPCO or similar specialist preferred
+ Certified Fraud Examiner and/or AHFI professional designations preferred
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Pay Range: $21.82 - $51.06 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
Molina Healthcare...Global investment management firm is seeking an Investment Transitions & Operations Associate at their global headquarters in West Los Angeles. This is an exciting opportunity for an experienced business operations professional within the financial services industry to...
*The Opportunity:* Are you an experienced family law attorney looking for a new home where you can truly make a difference? Do you... .... Our attorneys are respected and known for being level-headed advocates who resolve conflicts amicably and effectively. We handle divorce...
...Senior Web Application Engineer Position: Senior Web Application Engineer Location: Hybrid (3 days onsite) Hollywood, Fl Duration: 6 months Rate: Doe U.S. citizens and those who are authorized to work independently in the United States are encouraged to apply. We are...
...understanding of digital roadmaps for the coming year Influence the growth of the overall business Requirements Fluent in French & English Articulate, with strong written & verbal communication skills and a talent for building rapport and accelerating...
...Data Center/Cloud Architect Cisco UCSX / VMware Position Overview The Data Center/Cloud Architect Cisco UCSX / VMware is responsible for designing, implementing, maintaining, and optimizing enterprise-grade data center and hybrid cloud environments with a strong...