Job Description

Job Summary

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.

Job Duties

• 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/or 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.

Job Qualifications

Graduate from an Accredited School of Nursing.

Five years clinical nursing experience with broad clinical knowledge.

Five years experience conducting medical review and coding/billing audits involving professional and facility based services.

Knowledge and understanding of medical terminology along with demonstrated knowledge of CPT, ICD-9, HCPCS and DRG requirements.

Two years of managed care experience.

Active, unrestricted State Registered Nursing (RN) license in good standing.

Bachelor’s Degree in Nursing

Experience in government programs (i.e., Medicare, Medicaid, & SCHIP).

Experience in long-term care.

OHIO:
Transitions of Care for New Members

Molina Healthcare of Ohio follows the transition of care requirements outlined below and in Appendix D of the contract for new members transitioning to the MCO from fee-for-service (FFS) or another MCO. The Transition of Care Coach will coordinate all services with new members to ensure a seamless transition and ensure continuity of care.

Provision of Member Information

Pre-Enrollment Planning

The Molina Transition of Care Coach coordinates with and utilizes data provided by ODM, another MCO, the OhioRISE Plan (when applicable) and or collected by Molina (e.g. through assessments, new member outreach in advance of the member’s enrollment effective date) to identify existing sources of care and to ensure each new member is able to continue to receive existing services without disruption.

For OhioRISE Plan enrolled members, Molina will reach out to the OhioRISE Plan and primary care coordination staff to engage the OhioRISE Plan in pre-enrollment planning

Continuation of Services for Members

Documentation of Transition of Services

Transitions of Care Between Health Care Settings

Transitions of Care Between Molina Healthcare of Ohio and the OhioRISE Plan

Care Coordination Assignment

Provision of Member Information

Continuation of Services for Members

Documentation of Transition of Services

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.

• Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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