Investigator, Coding SIU Job at Molina Healthcare, Long Beach, CA

Vm5DSkltTGdxK2txVXhzWW5PZ1MzN1Z3TGc9PQ==
  • Molina Healthcare
  • Long Beach, CA

Job Description

Job Description

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.
  • 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

Licensed registered nurse (RN), Licensed practical nurse (LPN) and/or 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. Molina Healthcare

Job Tags

Contract work, Local area,

Similar Jobs

GardaWorld

Airport Call Off Security Job at GardaWorld

 ...Job Description GardaWorld Security Services is Now Hiring a Response Security Officer! Ready to suit up as a Special Response Security Guard What matters most in a role like this is your ability to adapt from one mission to the next. Tell us about how you... 

Clean Harbors

Owner Operator Job at Clean Harbors

 ...Clean Harbors is looking for a OTR Class A Dry Van Owner Operator to join their safety conscious team in Syracuse, NY! This route runs from Northeast region to OH and and flexible to go other lane/regions. Averages 2800 to 3000 miles per week. Drivers also can be domiciled... 

Tylin

Construction Manager - Complex Bridge Structures Job at Tylin

Are you a licensed Engineer or Construction Manager with experience in complex bridge technical construction engineering and design coordination on job sites? TYLin, a global leader in infrastructure engineering consulting, is looking for an experienced Construction Manager... 

My Next Stage

Associate Director of CMC, Quality Assurance (San Diego) Job at My Next Stage

 ...Associate Director of Chemistry, Manufacturing & Controls (CMC) - Quality Assurance develops and drives Quality (manufacturing and analytical)...  ...includes site-essential, site-by-design, field-based and remote-by-design jobs. The occupancy type that you are assigned is determined... 

CompHealth

Internal Medicine Physician Is Needed for Locum Tenens Help in VA Job at CompHealth

 ...Internal Medicine Physician Is Needed for Locum Tenens Help in VA at CompHealth summary: This locum tenens opportunity seeks an Internal...  ...duties, supported by comprehensive credentialing, housing, travel, and malpractice arrangements. The role emphasizes flexible scheduling...