Talent.com
Molina Healthcare
Investigator, Special Investigative Unit Coding-Miami FloridaMolina Healthcare • Miami, FL, United States
No longer accepting applications
Investigator, Special Investigative Unit Coding-Miami Florida

Investigator, Special Investigative Unit Coding-Miami Florida

Molina Healthcare • Miami, FL, United States
25 days ago
Job type
  • Full-time
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.

Job Requirements

  • At least 2 years CPT coding experience in a surgical, hospital and/or clinic setting, or equivalent combination of relevant education and experience.
  • Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Professional Medical Auditor (CPMA), or American Academy of Professional Coders (AAPC) certified
  • Critical-thinking, problem-solving and analytical skills.
  • Ability to prioritize and manage multiple tasks.
  • Ability to work in a team setting.
  • Strong verbal/written communication skills, and presentation skills.
  • Microsoft Office suite (including Excel), and applicable software program(s) proficiency.
  • In some states, 5 years of experience working in a fraud, waste and abuse (FWA)/special investigations unit (SIU)/fraud investigations role may be required (dependent on state/contractual requirements).
  • Knowledge of investigative and law enforcement procedures with emphasis on fraud investigations.
  • Knowledge of Managed Care and the Medicaid, Medicare, and Marketplace programs.
  • Understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems.
  • Ability to research and interpret regulatory requirements.

Preferred Qualifications

  • Certified Professional Compliance Officer (CPCO).
  • Certified Fraud Examiner (CFE) and/or Accredited Health Care Fraud Investigator (AHFI).
  • Experience working in group health insurance, particularly within claims processing or operations.
  • Working knowledge of local, state and federal laws and regulations pertaining to health insurance, investigations and legal processes (commercial insurance, Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, etc.).
  • Experience with claims processing systems.
  • Ability to use Microsoft Excel/Access platforms working with large quantities of data.
  • Ability to answer questions, identify trends and patterns, and present findings.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

Create a job alert for this search

Investigator, Special Investigative Unit Coding-Miami Florida • Miami, FL, United States

Similar jobs

Travel CVOR Tech - $2,050 to $2,291 per week in Miami, FL

AlliedTravelCareersMiami, FL, US
$2,050.00 weekly
Full-time

AlliedTravelCareers is working with Prime Time Healthcare to find a qualified CVOR Tech in Miami, Florida, 33114!.Prime Time Healthcare is seeking a CVOR Tech for a travel assignment in Miami, FL t... Show more

 • Promoted

Travel MRI Tech - $1,877 to $2,077 per week in Cooper City, FL

AlliedTravelCareersMiami, Florida, US
$1,877.00–$2,077.00 weekly
Full-time

AlliedTravelCareers is working with Ventura MedStaff to find a qualified MRI Tech in Cooper City, Florida, 33328!.Are you ready to take your Travel career to the next level? See places you have no... Show more

 • Promoted • New!

Travel Interventional Radiology (IR) - $2,499 to $2,699 per week in Miami, FL

AlliedTravelCareersMiami, Florida, US
$2,499.00 weekly
Full-time

AlliedTravelCareers is working with Ventura MedStaff to find a qualified Interventional Radiology in Miami, Florida, 33133!.Are you ready to take your Travel career to the next level? See places y... Show more

 • Promoted

Travel Interventional Radiology (IR) - $1,920 per week in Miami, FL

AlliedTravelCareersMiami, Florida, US
$1,920.00 weekly
Full-time

AlliedTravelCareers is working with Medical Solutions to find a qualified Interventional Radiology in Miami, Florida, 33133!.A facility in Miami, FL is looking for an exceptional IR Technologist (I... Show more

 • Promoted

Travel Interventional Radiology (IR) - $1,728 per week in Miami, FL

AlliedTravelCareersMiami, FL, US
$1,728.00 weekly
Full-time

AlliedTravelCareers is working with Medical Solutions to find a qualified Interventional Radiology in Miami, Florida, 33133!.A facility in Miami, FL is looking for an exceptional IR Technologist (I... Show more

 • Promoted

Medical Billing and Coding - Entry Level Training Program

Dreambound Inc.Brownsville, Florida, US
Full-time

Note : This is an educational program, not a job.Successful completion of the program does not guarantee employment but will equip you with valuable skills for the healthcare job market.Looking to ... Show more

 • Promoted

Travel MRI Tech - $2,063 per week in Davie, FL

AlliedTravelCareersMiami, Florida, US
$2,063.00 weekly
Full-time

AlliedTravelCareers is working with Convergence Medical Staffing to find a qualified MRI Tech in Davie, Florida, 33328!.Job Tech,Travel - MRI Tech (734) - HCA Florida University - 12:00PM - 8:30PM... Show more

 • Promoted • New!

Travel Radiology Tech - $2,559 per week in Miami, FL

AlliedTravelCareersMiami, Florida, US
$2,559.00 weekly
Full-time

AlliedTravelCareers is working with Convergence Medical Staffing to find a qualified Rad Tech in Miami, Florida, 33133!.Job Tech,Travel - IR Tech (727) - HCA Florida Mercy -7:00AM - 3 :30PM, City:... Show more

 • Promoted

Travel Ultrasound Tech in Fort Myers, FL

AlliedTravelCareersMiami, Florida, US
Full-time

Competitive weekly pay (inquire for details) .AlliedTravelCareers is working with SkyBridge Healthcare to find a qualified Ultrasound in Fort Myers, Florida, 33912!.SkyBridge Healthcare is currentl... Show more

 • Promoted

Travel Interventional Radiology (IR) in Miami, FL

AlliedTravelCareersMiami, FL, US
Full-time

Competitive weekly pay (inquire for details) .Comprehensive health, prescription, dental, vision, life, and disability plans.Referral opportunities ? Refer a friend & Cash in!.Travel reimbursem... Show more

 • Promoted

Travel Interventional Radiology (IR) - $2,680 per week in Miami, FL

AlliedTravelCareersMiami, Florida, US
$2,680.00 weekly
Full-time

AlliedTravelCareers is working with MedPro Healthcare Staffing to find a qualified Interventional Radiology in Miami, Florida, 33114!.Joint Commission-certified staffing agency, is seeking a qualit... Show more

 • Promoted

Travel Interventional Radiology (IR) - $2,460 per week in Miami, FL

AlliedTravelCareersMiami, Florida, US
$2,460.00 weekly
Full-time

AlliedTravelCareers is working with OneStaff Medical to find a qualified Interventional Radiology in Miami, Florida, 33133!.An independently-owned, nationally-recognized and amazingly awesome sta... Show more

 • Promoted

SENIOR INVESTIGATOR - 1 1 1

Florida State JobsMiami, FL, United States
Full-time

Senior InvestigatorThe State Personnel System is an E-Verify employer.For more information, click on our E-Verify Website.The Office represents the State of Florida in state and federal civil and c... Show more

 • Promoted

Travel MRI Tech - $1,864 to $2,094 per week in Davie, FL

AlliedTravelCareersMiami, Florida, US
$1,864.00–$2,094.00 weekly
Full-time +1

AlliedTravelCareers is working with Aya Healthcare to find a qualified MRI Tech in Davie, Florida, 33312!.Aya Healthcare has an immediate opening for the following position: MRI Tech in Davie, FL.W... Show more

 • Promoted

Travel MRI Tech - $1,923 per week in Davie, FL

AlliedTravelCareersMiami, Florida, US
$1,923.00 weekly
Full-time

AlliedTravelCareers is working with Atlas MedStaff to find a qualified MRI Tech in Davie, Florida, 33328!.Atlas Medstaff is currently seeking candidates in the MRI Tech (MRI Tech) profession for a ... Show more

 • Promoted

Travel Interventional Radiology (IR) - $2,559 per week in Miami, FL

AlliedTravelCareersMiami, FL, US
$2,559.00 weekly
Full-time

Coast Medical Service is a nationwide travel nursing & allied healthcare staffing agency dedicated to providing an elite traveler experience for the experienced or first-time traveler.Coast is ... Show more

 • Promoted

Seeking Bodily Injury Claims AdjustersMiami, Florida, United States

Morgan & Morgan, P.A.Miami, FL, United States
Full-time

Bodily Injury Claims Adjusters.At Morgan & Morgan, the work we do matters.For millions of Americans, we're their last line of defense against insurance companies, large corporations or defective go... Show more

 • Promoted

Travel Interventional Radiology (IR) - $2,674 per week in Miami, FL

AlliedTravelCareersMiami, FL, US
$2,674.00 weekly
Full-time

AlliedTravelCareers is working with MedPro Healthcare Staffing to find a qualified Interventional Radiology in Miami, Florida, 33114!.Joint Commission-certified staffing agency, is seeking a qualit... Show more

 • Promoted

Travel Interventional Radiology (IR) - $1,612 per week in Miami, FL

AlliedTravelCareersMiami, FL, US
$1,612.00 weekly
Full-time

A facility in Miami, FL is looking for an exceptional IR Technologist (Interventional Radiology) for a Local Contract.If you’re seeking flexibility and variety in your career, this could be the per... Show more

 • Promoted

Travel Interventional Radiology (IR) - $2,167 per week in Miami, FL

AlliedTravelCareersMiami, Florida, US
$2,167.00 weekly
Full-time

AlliedTravelCareers is working with OneStaff Medical to find a qualified Interventional Radiology in Miami, Florida, 33133!.An independently-owned, nationally-recognized and amazingly awesome sta... Show more