Job Description

Job Description

Job Summary
Provides senior level support for special investigation unit (SIU) activities. Responsible for supporting for the prevention, detection, investigation, reporting, and when appropriate, recovery of money related to health care fraud, waste, and abuse (FWA). Responsible for reviewing and analyzing information to draw conclusions on allegations of FWA and/or may determine appropriateness of care, and recognizing and adhering to national and local coding and billing guidelines in order to maintain coding accuracy and excellence.
Essential Job Duties
• Responds to allegations of potential fraud, waste and abuse (FWA); conducts the investigation of fraudulent, wasteful and abusive activities involving members and providers.
• Analyzes enrollment data, medical claims data, contract terms, financial records, provider and member claims history, and other documentation to determine FWA and identify potential patterns.
• Applies regulatory and contractual requirements as well as internal policies and procedures to the case investigation process.
• Perform data analysis, research and review of claims data to identify trends, patterns, outliers and emerging issues in health care FWA with fraud technology.
• Conducts investigations and interviews to gather additional evidence.
• Researches and investigates member identity theft cases through internal Alertline.
• Communicates with members and providers routinely regarding issues including investigative findings, recoveries, and educational feedback where appropriate.
• Compiles, reports and presents case information to the appropriate Medicaid fraud control unit or other regulatory agency.
• Maintains the integrity of documentation for FWA cases; updates the case management system to ensure documentation of all calls, evidence, referrals, inquiries and case events are accurate for record keeping purposes and for "discovery" in court related cases.
• Establishes and maintains strong relationships with external agencies including the Department of Health and Human Services (DHHS), Office of Inspector General (OIG), Drug Enforcement Administration (DEA), state professional licensing boards, US Attorney's office and state/local law enforcement agencies.
• Prepares data requests from external law enforcement agencies as required.
• Travels to conduct provider onsite audits and investigations.
• Writes clear and concise reports, presents findings to providers and participates in negotiated resolution of issues at the direction of management.
Tracks and reports any overpayment as a result of an investigation.
• Uses findings to determine where there is a need for a change in policy and course of appropriate action based on line of business, severity of issue, regulatory compliance requirements and plan exposure.
• Vets new concepts for building additional investigation opportunities/clearer review guidelines for cases.
• Assist SIU leadership in case review and resolution.
• Provides guidance to investigators as needed on investigative techniques, tools, or strategy.
• Effectively investigates and manages complex and non-complex fraud allegations.
• Develops and maintains relationships with key business units within specific product line and geographic region.
• Provides direction, instructions and guidance to Investigative team, particularly in the absence of SIU leadership.
• Creates, edits, and updates assigned reports to apprise the company on the team's progress.
• Provides training and support to new and existing SIU team members.

Required Qualifications
• At least 3 years investigative experience in the health care industry, or equivalent combination of relevant education and experience.
• Valid and unrestricted driver's license.
• Proven investigatory skills including ability to organize, analyze, and effectively determine risk with corresponding solutions, and remain objective and separate facts from opinions.
• 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 health care delivery systems.
• Understanding of datamining and use of data analytics to detect FWA.
• Ability to research and interpret regulatory requirements.
• Effective interpersonal skills and customer service focus ability to interact with individuals at all levels.
• Strong presentation skills with ability to create and deliver training, informational and other types of programs.
• Strong logical, analytical, critical-thinking and problem-solving skills.
• Strong sense of initiative, excellent follow-through, and persistence in locating and securing needed information.• Fundamental understanding of audits and corrective actions.
• Ability to multi-task and operate effectively across geographic and functional boundaries.
• Detail-oriented, self-motivated, and able to meet tight deadlines.
• Ability to develop realistic, motivating goals and objectives, track progress and adapt to changing priorities.
• Energetic and forward-thinking with high ethical standards and a professional image.
• Collaborative and team-oriented.
• Effective verbal and written communication skills.
• Microsoft Office suite (Word, Excel, PowerPoint, Outlook), SharePoint, Intranet/Internet, and applicable software program(s) proficiency, and ability and experience incorporating/merging documents from various applications.

Preferred Qualifications
• Accredited Health Care Fraud Examiner (AHFI) and/or Certified Fraud Examiner (CFE).

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.