Provides investigative support for special investigation unit (SIU) activities related to medical provider coding fraud, waste, and abuse (FWA). Investigates and resolves healthcare fraud and abuse cases involving medical providers using information from member benefits and medical records after review of post-payment claims.
Essential Job Duties
- Independently re-evaluate medical claims and associated records by applying advanced coding knowledge, applicable federal and state regulatory requirements, and Molina policies.
- Review post-pay claims against corresponding medical records to determine claim payment accuracy.
- Manage documents and prioritize caseloads to ensure timely turnaround.
- Ensure adherence to state, federal, and internal policies, CPT guidelines, and provider contract requirements.
- Prepare clinical summaries after review.
- Communicate and participate in case-related meetings.
- Complete medical reviews to support referral to law enforcement or payment recovery.
- Support investigation work as needed and required by regulatory agencies.
Requirements & Qualifications
Qualifications
- At least 2 years of CPT coding experience in a surgical, hospital, and/or clinic setting, or an equivalent combination of education and experience.
- CPC, CCS, CPMA, or other AAPC certification.
- Strong critical-thinking, problem-solving, and analytical skills.
- Ability to prioritize and manage multiple tasks.
- Ability to work effectively in a team environment.
- Strong verbal, written, and presentation communication skills.
- Proficiency with Microsoft Office Suite, including Excel, and related software.
- In some states, 5 years of experience in fraud, waste, and abuse (FWA), SIU, or fraud investigations may be required.
- Knowledge of investigative and law enforcement procedures with emphasis on fraud investigations.
- Knowledge of managed care and Medicaid, Medicare, and Marketplace programs.
- Understanding of claim billing codes, medical terminology, anatomy, and healthcare delivery systems.
- Ability to research and interpret regulatory requirements.
Preferred Qualifications
- CPCO certification.
- CFE and/or AHFI certification.
- Experience in group health insurance, especially claims processing or operations.
- Working knowledge of local, state, and federal laws and regulations related to health insurance, investigations, and legal processes.
- Experience with claims processing systems.
- Ability to use Microsoft Excel and Access with large data sets.
- Ability to identify trends and patterns and present findings.
Benefits & Perks
Competitive benefits and compensation package.
Location
Miami, Florida, US
Employment Type
Full-time
Experience Level
Intermediate Level
Remote work allowed
No
Posted
4 weeks ago
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