JOIN OUR TEAM

Overview

As an integral member of our Special Investigation Unit (SIU), you will play a crucial role in the ongoing battle against healthcare fraud, waste, and abuse. Our SIU Investigator is dedicated to identifying, investigating, and reporting on potentially fraudulent activities within the healthcare system, ensuring the integrity of our services. You will conduct thorough medical review audits, including comprehensive coding and billing evaluations, to support this mission. Your analytical skills will be key in assessing allegations of fraud and appropriate care, all while adhering to national and local coding guidelines to ensure meticulous accuracy. You will produce detailed audit reports for both internal and external reviews, collaborating with various departments including Compliance and Legal, to maintain robust anti-fraud oversight.

Key Responsibilities

• Identify and develop leads for investigating potential instances of fraud, waste, or abuse using evidence-based assessments.
• Conduct preliminary evaluations as well as comprehensive investigations, including witness interviews, background checks, data analysis for unusual billing patterns, and contract research.
• Ensure all investigations are completed in accordance with state and federal regulations within designated timelines.
• Perform both onsite and desk-based investigations to gather necessary documentation.
• Execute thorough reviews of medical records and utilize data analysis to determine the existence of fraudulent activities.
• Collaborate with internal departments such as Provider Services and Claims to enhance the investigation process.
• Utilize utilization reviews to detect aberrant billing behaviors indicative of healthcare fraud.
• Prepare and submit FWA referrals to appropriate regulatory and law enforcement bodies.
• Maintain accurate records within the case management system, ensuring compliance with SIU documentation standards.
• Educate providers on coding practices grounded in national guidelines and contractual requirements.
• Engage with regulatory authorities and law enforcement during case investigations.
• Draft audit result letters to inform providers of identified overpayments.
• The work may include remote, office-based, and field travel throughout New York State as needed.
• Adhere to all applicable contracts and regulations to ensure compliance.
• Follow SIU policies and objectives set forth by SIU leadership.
• Assist the SIU during arbitrations, legal proceedings, and settlement negotiations.
• Actively participate in Multi-Agency Fraud Control Unit (MFCU) meetings focused on case development and referrals.

Qualifications

Education

A Bachelor’s degree or Associate’s Degree in Criminal Justice or a similar field, or an equivalent combination of education and experience.

Experience, Knowledge, Skills & Abilities

• 1-3 years of relevant experience, with additional requirements as dictated by state contract.
• Strong investigative abilities, with a talent for organizing and analyzing information to assess risk and propose solutions.
• Familiarity with fraud investigation procedures and managed care systems, including Medicaid and Medicare.
• Understanding of medical billing codes, medical terminology, anatomy, and healthcare delivery systems.
• Proficient in data mining and analytics aimed at detecting fraudulent practices.
• Ability to research and interpret regulatory guidelines effectively.
• Strong interpersonal skills and a customer-focused approach, capable of communicating with individuals across all levels.
• Exceptional written and verbal communication skills, with experience in creating and delivering training materials.
• Advanced proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook), SharePoint, and web applications.
• Demonstrated logical reasoning, analytical thinking, and problem-solving capabilities.
• Self-motivated with excellent follow-through, persistence in securing necessary information.
• Keen understanding of audits and corrective actions.
• Adept at balancing multiple tasks and operating across diverse geographic and functional areas.
• Detail-oriented and deadline-driven with the ability to create and pursue realistic objectives.
• Dynamic, ethical, and professional demeanor with a collaborative mindset.

Required Certifications

• A valid driver’s license is required.

Preferred Experience

A minimum of 5 years in fraud, waste, and abuse investigations or related fields.

Preferred Certifications

• Health Care Anti-Fraud Associate (HCAFA)
• Accredited Health Care Fraud Investigator (AHFI)
• Certified Fraud Examiner (CFE)

Current Molina employees interested in this opportunity are encouraged to apply through the internal job portal.

Molina Healthcare provides a competitive compensation and benefits package. We are proud to be an Equal Opportunity Employer (EOE) M/F/D/V.

Compensation Range: $21.82 – $51.06 / HOURLY

Please note that actual compensation may vary based on geographic location, work experience, education, and skill level.