Job Summary The Special Investigation Unit (SIU) Investigator is responsible for supporting the prevention, detection, investigation, reporting, and when appropriate, recovery of money related to health care fraud, waste, and abuse. Duties include performing accurate and reliable medical review audits that may also include coding and billing reviews. The SIU Investigator is responsible for reviewing and analyzing information to make medical determinations as necessary, and applies clinical knowledge to assess the medical necessity, level of services, and/or appropriateness of care in cases. The SIU Investigator is also responsible for recognizing and adhering to national and local coding and billing guidelines in order to maintain coding accuracy and excellence. The position also entails producing audit reports for internal and external review. The position may also work with other internal departments, including Compliance, Corporate Legal Counsel, and Medical Affairs, in order to achieve and maintain appropriate anti-fraud oversight.
Knowledge/Skills/Abilities • Perform objective desk and onsite medical record audits to verify if services were supported by documentation, to determine if services were appropriately administered, and/or to validate coding/billing accuracy. • Conduct interviews of providers and/or health plan members in order to determine whether fraud, waste, or abuse may have occurred. • Coordinate with various internal customers (e.g., Provider Services, Contracting and Credentialing, Healthcare Services, Member Services, Claims) to gather documentation pertinent to investigations. • Detect potential health care fraud, waste, and abuse through the identification of aberrant coding and/or billing patterns through utilization review. • Incorporate leadership and communication skills to work with physicians and other health professionals when investigating cases. • Generate and provide accurate and timely written reports for internal and/external use detailing audit findings. • Render provider education on appropriate practices (e.g., coding) as appropriate based on national or local guidelines, contractual, and/or regulatory requirements. • Identify opportunities for improvement through the audit process and provide recommendations for system enhancement in order to augment investigative outcomes and performance.
Required Education Registered Nurse or BSN
Required Experience • Five years clinical experience with broad clinical knowledge. • Five years experience conducting medical review and coding/billing audits involving professional and facility based services. • Knowledge and understanding of medical terminology along with comprehension of CPT, ICD-9, ICD-10 HCPCS and DRG requirements. • 2 years experience in managed care. • Experience in Coding. • 10% travel for onsite audits.
Preferred Experience • Experience in government programs (i.e., Medicare, Medicaid, & SCHIP). • Experience in long-term care.
Internal Number: 1800070
About Molina Healthcare
Molina Healthcare, a FORTUNE 500, multi-state health care organization, arranges for the delivery of health care services and offers health information management solutions to nearly five million individuals and families who receive their care through Medicaid, Medicare and other government-funded programs in fifteen states.