Investigator, Coding SIU Job at Molina Healthcare, Tucson, AZ

YTRNbXE1QnV0WC9DK2Z3Y2VFenpRZjZjVHc9PQ==
  • Molina Healthcare
  • Tucson, AZ

Job Description

**JOB DESCRIPTION** **Job Summary** The SIU Coding Investigator is responsible for investigating and resolving instances of healthcare fraud and abuse by medical providers. This position uses information from a tip, member benefits, and medical records to document relevant findings of a post pay clinical review. This position manages documents and prioritizes case load to ensure timely turn around. This position ensures adherence to state and federal policies, CPT guidelines, internal policies, and contract requirements. This position completes a medical review to facilitate a referral to law enforcement or for payment recovery. **KNOWLEDGE/SKILLS/ABILITIES** + Reviews post pay claims with corresponding medical records to determine accuracy of claims payments. + Review of applicable policies, CPT guidelines, and provider contracts. + Devise clinical summary post review. + Communicate and participate in meetings related to cases. + Critical thinking, problem solving and analytical skills. + Ability to prioritize and manage multiple tasks. + Proven ability to work in a team setting. + Excellent oral and written communication skills and presentation skills. **JOB QUALIFICATIONS** **Required Education** High School Diploma / GED (or higher) **Required Experience** + 3+ years CPT coding experience (surgical, hospital, clinic settings) or 5+ years of experience working in a FWA / SIU or Fraud investigations role for New Jersey/New York location + Thorough knowledge of PC based software including Microsoft Word (edit/save documents) and Microsoft Excel (edit/save spreadsheets, sort/filter) **Required License, Certification, Association** Licensed registered nurse (RN), Licensed practical nurse (LPN) and/or Certified Coder (CPC, CCS, and/or CPMA) **Preferred Education** Bachelor's degree (or higher) **Preferred Experience** + 2+ years of experience working in the group health business preferred, particularly within claims processing or operations. + A demonstrated working knowledge of Local, State & Federal laws and regulations pertaining to health insurance, investigations & legal processes (Commercial insurance, Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, etc.) + Experience with UNET, Comet, Macess/CSP, or other similar claims processing systems. + Demonstrated ability to use MS Excel/Access platforms working with large quantities of data to answer questions or identify trends and patterns, and the ability to present those findings. **Preferred License, Certification, Association** + AAPC Certified Medical CPC, CPMA, CPCO or similar specialist preferred + Certified Fraud Examiner and/or AHFI professional designations preferred 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. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $21.82 - $51.06 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Tags

Hourly pay, Contract work, Work experience placement, Local area,

Similar Jobs

Mortgage Career Exchange

Operations | Entry Level & Career Changer | Loan Closer | Shipper | Disclosure Desk Job at Mortgage Career Exchange

 ...Top US Home Builder Mortgage company is looking to add Quality Professionals to their Team in Pittsburgh. No prior mortgage experience necessary. Your desire to excel is matched by a commitment to your success and you'll have the tools and industry knowledge you need... 

LVI Associates

Site Safety Officer Job at LVI Associates

 ...Our client is seeking a highly experienced and dedicated Site Safety Officer to join their team in Tracy, California. This role is critical to ensuring the highest standards of safety are maintained across their heavy civil construction projects, with a strong emphasis... 

Russell Tobin

Industrial Engineering Intern Job at Russell Tobin

 ...supporting a world-class organization to hire an "Industrial Engineer" near Forest city, IA. Key Responsibilities: Learn and support...  ...safety improvement projects is required Candidates with mechanical engineering backgrounds will be considered Candidates with... 

Louisiana Delta Community College

IT Director Job at Louisiana Delta Community College

 ...Technology Type of Appointment: Unclassified - Administrative/Staff Duties and Responsibilities: Lead and manage the IT department, including networking, cybersecurity, VMWare, Windows Server, Active Directory, Office 365, and more. Develop and implement... 

Rag & Bone

Email Marketing & SMS Specialist Job at Rag & Bone

 ...have a voice on policy, process, and collaboration for a more equitable future. Job Summary: The specialist will be responsible for managing email and SMS marketing campaigns, creating automated flows, analyzing marketing performance, generating leads, setting up marketing...