JOB DESCRIPTION

Essential Job Duties

• Independently re-evaluates medical claims and associated records by applying knowledge of advanced coding, applicable federal and state regulatory requirements, and Molina policies. • Reviews post-pay claims against corresponding medical records to determine accuracy of claims payments. • Manages documents and prioritizes caseloads to ensure timely turnaround. • Ensures adherence to applicable state/federal/internal policies, Current Procedural Terminology (CPT) guidelines and provider contract requirements. • Devises clinical summary post-review. • Communicates and participates in meetings related to cases. • Completes medical review to facilitate referral to law enforcement or payment recovery. • Supports investigation work as necessary and required by the regulatory agency.

Job Requirements

• At least 2 years of CPT coding experience in a surgical, hospital and/or clinic setting, or equivalent combination of relevant education and experience. • Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Professional Medical Auditor (CPMA), or American Academy of Professional Coders (AAPC) certified. • Critical-thinking, problem-solving and analytical skills. • Knowledge of investigative and law enforcement procedures with emphasis on fraud investigations. • Knowledge of managed care and the Medicaid, Medicare, and Marketplace programs. • Understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems. • Ability to research and interpret regulatory requirements. • Ability to prioritize and manage multiple tasks.

• Ability to work in a team setting.

• Strong verbal/written communication skills, and presentation skills. • Microsoft Office suite (including Excel), and applicable software program(s) proficiency. • In some states, 5 years of experience working in a fraud, waste and abuse (FWA)/special investigations unit (SIU)/fraud investigations role may be required (dependent on state/contractual requirements).

Preferred Qualifications

• Certified Professional Compliance Officer (CPCO).Certified Fraud Examiner (CFE) and/or Accredited Health Care Fraud Investigator (AHFI). • Experience working in group health insurance, particularly within claims processing or operations. • Working knowledge of local, state and federal laws and regulations pertaining to health insurance, investigations and legal processes (commercial insurance, Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, etc.). • Experience with claims processing systems. • Ability to use Microsoft Excel platform and work with large quantities of data. • Ability to answer questions, identify trends and patterns, and present findings."

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