Investigator, Special Investigative Unit Coding (Remote)

Job description

JOB DESCRIPTION: Provides investigative support for special investigation unit (SIU) activities specific to medical provider coding fraud, waste and abuse (FWA). Investigates and resolves instances of health care fraud and abuse investigations of medical providers using informational tips from member benefits and medical records following review of post-payment claims. Essential Job Duties: - Independently re-evaluates medical claims and associated records by applying knowledge of advanced coding, all relevant and applicable Federal and State regulatory requirements, and Molina policies. - Reviews post-pay claims against corresponding medical records to determine accuracy of claims payments. - Manages documents and prioritizes caseloads to ensure timely turnaround. - Ensures adherence to applicable state/federal/internal policies, Current Procedural Terminology (CPT) guidelines and provider contract requirements. - Devises clinical summary post-review. - Communicates and participates in meetings related to cases. - Completes medical review to facilitate referral to law enforcement or payment recovery. - Supports investigation work as necessary and required by the regulatory agency....