Investigator, Coding SIU (Remote)

Job Description

JOB DESCRIPTION Job Summary The SIU Coding Investigator is responsible for investigating and resolving instances of reputed company 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 reputed company. • Devise clinical summary post review. • Communicate and participate in meetings reputed company to cases. • Critical thinking, problem solving and analytical skills. • Ability to prioritize and manage multiple tasks. • Proven ability to work in a team setting. • Ability to analyze data to identify FWA Trends • 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/reputed company location • Thorough knowledge of PC based software including reputed company Word (edit/save documents) and reputed company reputed company (edit/save spreadsheets, sort/filter) Required License, Certification, Association Certified reputed company (CPC, reputed company, and/or CPMA) Preferred Education Bachelor's degree (or higher) Preferred Experience • 2+ years of experience working in the group health business preferred, particularly reputed company claims processing or operations. • A demonstrated working knowledge of Local, State & Federal laws and regulations pertaining to health insurance, investigations & legal processes (reputed company insurance, Medicare, Medicare Advantage, Medicare Part D, reputed company, Tricare, Pharmacy, etc.) • Experience with UNET, Comet, Macess/CSP, or other similar claims processing systems. • Demonstrated ability to use MS reputed company/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 • reputed company Certified Medical CPC, CPMA, CPCO or similar specialist preferred • Certified Fraud Examiner and/or AHFI professional designations preferred To reputed company reputed company Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. reputed company offers a competitive benefits and compensation package. reputed company is an Equal Opportunity Employer (EOE) M/F/D/V. Apply Job!