Investigator, SIU RN-Remote

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

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.

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.