Lead, Special Investigation Unit (Remote)
Molina Healthcare Arizona; Kenosha, Wisconsin; Orlando, Florida; Tampa, Florida; Macon, Georgia; Iowa; Sioux City, Iowa; Des Moines, Iowa; Owensboro, Kentucky; Ann Arbor, Michigan; Grand Island, Nebraska; New York; Akron, Ohio; Phoenix, Arizona; Tacoma, Washington; Bellevue, Washington; Milwaukee, Wisconsin; Dallas, Texas; Iowa City, Iowa; Davenport, Iowa; Covington, Kentucky; Lincoln, Nebraska; Rochester, New York; Columbus, Ohio; Jacksonville, Florida; Provo, Utah; Washington; Savannah, Georgia; Columbus, Georgia; Georgia; Cedar Rapids, Iowa; Caldwell, Idaho; Detroit, Michigan; Roswell, New Mexico; Santa Fe, New Mexico; New York, New York; Buffalo, New York; Cincinnati, Ohio; Houston, Texas; Austin, Texas; Scottsdale, Arizona; West Valley City, Utah; Spokane, Washington; Madison, Wisconsin; Meridian, Idaho; Lexington-Fayette, Kentucky; Michigan; Sterling Heights, Michigan; Kearney, Nebraska; Texas; San Antonio, Texas; Mesa, Arizona; Miami, Florida; Seattle, Washington; Vancouver, Washington; Racine, Wisconsin; Augusta, Georgia; Boise, Idaho; Omaha, Nebraska; Tucson, Arizona; Green Bay, Wisconsin; Wisconsin; Idaho; Kentucky; Grand Rapids, Michigan; Albuquerque, New Mexico; Rio Rancho, New Mexico; Dayton, Ohio; Orem, Utah; Salt Lake City, Utah; Utah; Nampa, Idaho; Bowling Green, Kentucky; Warren, Michigan; Bellevue, Nebraska; Nebraska; Las Cruces, New Mexico; Syracuse, New York; Yonkers, New York; Cleveland, Ohio; St. Petersburg, Florida; Atlanta, Georgia; Layton, Utah; Idaho Falls, Idaho; Louisville, Kentucky; New Mexico; Ohio; Fort Worth, Texas; Chandler, Arizona; Florida Job ID 2030286JOB DESCRIPTION
Job Summary
Under direct supervision of the Manager, SIU, the Team Lead is responsible to lead a small team of investigators and provide oversight on daily investigative activities as a back-up to the SIU Manager. This position will be accountable for tracking on investigations conducted by his/her team and will provide oversight and guidance throughout the life of an investigation as well as QA reviews and approvals. In addition to leading a team of investigators and analysts, the Team Lead will ensure the Manager is aware of any major case developments, and ensure cases are being investigated according to the SIU's standards. Position must have thorough knowledge of Medicaid/Medicare/Marketplace health coverage audit policies and be able to apply them in ensuring program compliance via payment integrity programs. The position must have the ability to determine correct coding, documentation, potential fraud, abuse, and over utilization by providers and recipients. The position will review claims data, medical records, and billing data from all types of healthcare providers that bill Medicaid/Medicare/Marketplace.
KNOWLEDGE/SKILLS/ABILITIES
- Ensure investigators are managing their cases effectively and in accordance with SIU policies, processes, quality standards, and procedures.
- Ensure that investigators are managing their respective State Reporting requirements and assignments effectively and timely.
- Manage the flow of day-to-day investigations.
- Perform assessment that QA measures were complete and signed-off
- Provide guidance to investigators as needed on investigative techniques, tools, or strategy.
- Effectively investigate and manage complex and non-complex fraud allegations.
- Develop and maintain relationships with key business units within specific product line and geographic region.
- Provides direction, instructions, and guidance to Investigative team, particularly in the absence of the SIU Manager.
- Provide training to team members as needed.
- Communicate clear instructions to team members, listen to team members' feedback.
- Monitor team members' participation to ensure the training provided is effective, and if any additional training is needed.
- Create, edit, and update assigned reports to apprise the company on the team's progress.
- Distribute reports to the appropriate personnel.
JOB QUALIFICATIONS
Required Education
High School/GED.
Required Experience
- Ability to work independently with minimal supervision and manage a high volume of assignments.
- Strong verbal and written communication skills.
- High degree of integrity and confidentiality required handling information that is considered personal and confidential.
- Analytical skills and ability to make deductions, logical and sequential thinker.
- 2+ years of experience conducting comprehensive healthcare fraud investigations; interacting with state, federal and local law enforcement agencies, as necessary.
- SIU Process/Systems Expertise.
- MCO Experience.
- Fraud Investigation Subject Matter Expert (SME).
- Proficient knowledge and experience in the Fraud, Waste, and Abuse field.
- Knowledge and experience in Medicaid/Medicare/Marketplace healthcare.
- Knowledge of healthcare coding, billing and Medicaid/Medicare/Marketplace policy, Federal regulation and/or State laws, rules, and guidelines.
- Demonstrated proficiency in analyzing the quality and necessity of health care services (inpatient and community based) and communicate results effectively.
- Proficiency in research, understanding, interpreting and application of government rules/regulations/policies
- Ability to conduct research, gather information and analyze a variety of data.
- Strong computer skills required, including working knowledge of the usage of E-mail, MS word and Excel; strong communication skills, both oral and written; prior experience in a leadership role desired.
- Required License, Certification, Association
- Healthcare Anti-Fraud Associate (HCAFA), Accredited Health Care Fraud Examiner (AHFI) and/or Certified Fraud Examiner (CFE) preferred.
- Valid driver’s license required.
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: $24 - $56.17 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
About Us
Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Job Type: Full Time Posting Date: 02/18/2025ABOUT OUR LOCATION
View Map- Lead Delegation Oversight Perf Manager Florida, Akron Ohio, Dallas Texas, Phoenix Arizona, Miami Florida, Orlando Florida, Salt Lake City Utah, Arizona, Texas, New Mexico, Michigan, Georgia, Idaho, Utah, Wisconsin 02/19/2025
- Risk & Quality Performance Manager (Remote) Arizona, Columbus Ohio, Green Bay Wisconsin, Milwaukee Wisconsin, Michigan, Grand Island Nebraska, Kearney Nebraska, St. Petersburg Florida, Des Moines Iowa, Sioux City Iowa, Covington Kentucky, New Mexico, New York New York, New York, Yonkers New York, Dayton Ohio, San Antonio Texas, Spokane Washington, Madison Wisconsin, Wisconsin, Bowling Green Kentucky, Detroit Michigan, Lincoln Nebraska, Tucson Arizona, Chandler Arizona, Iowa, Owensboro Kentucky, Akron Ohio, Texas, Fort Worth Texas, Vancouver Washington, Grand Rapids Michigan, Sterling Heights Michigan, Nebraska, Miami Florida, Davenport Iowa, Louisville Kentucky, Buffalo New York, Rochester New York, West Valley City Utah, Utah, Bellevue Washington, Ann Arbor Michigan, Warren Michigan, Scottsdale Arizona, Orlando Florida, Tampa Florida, Atlanta Georgia, Augusta Georgia, Macon Georgia, Iowa City Iowa, Cedar Rapids Iowa, Santa Fe New Mexico, Austin Texas, Houston Texas, Layton Utah, Lexington-Fayette Kentucky, Bellevue Nebraska, Florida, Georgia, Columbus Georgia, Caldwell Idaho, Idaho, Rio Rancho New Mexico, Dallas Texas, Provo Utah, Racine Wisconsin, Omaha Nebraska, Albuquerque New Mexico, Phoenix Arizona, Idaho Falls Idaho, Boise Idaho, Roswell New Mexico, Syracuse New York, Cleveland Ohio, Cincinnati Ohio, Ohio, Orem Utah, Tacoma Washington, Seattle Washington, Las Cruces New Mexico, Mesa Arizona, Jacksonville Florida, Meridian Idaho, Nampa Idaho, Kentucky, Salt Lake City Utah, Washington, Kenosha Wisconsin, Savannah Georgia 02/19/2025
- Sr Overreader, HEDIS/Quality Improvement (Remote) Arizona, Idaho, Bowling Green Kentucky, Grand Island Nebraska, Kearney Nebraska, Las Cruces New Mexico, New York, Rochester New York, New York New York, Yonkers New York, Ohio, Texas, Fort Worth Texas, Salt Lake City Utah, Seattle Washington, Florida, St. Petersburg Florida, Orlando Florida, Sioux City Iowa, Idaho Falls Idaho, Owensboro Kentucky, Grand Rapids Michigan, Detroit Michigan, Lincoln Nebraska, Santa Fe New Mexico, Cincinnati Ohio, Layton Utah, Tucson Arizona, Jacksonville Florida, Macon Georgia, Covington Kentucky, New Mexico, Spokane Washington, Washington, Bellevue Washington, Atlanta Georgia, Iowa, Meridian Idaho, Omaha Nebraska, Akron Ohio, West Valley City Utah, Vancouver Washington, Chandler Arizona, Kenosha Wisconsin, Columbus Georgia, Caldwell Idaho, Louisville Kentucky, Nebraska, Rio Rancho New Mexico, Roswell New Mexico, Dallas Texas, Houston Texas, San Antonio Texas, Utah, Tacoma Washington, Phoenix Arizona, Des Moines Iowa, Boise Idaho, Buffalo New York, Syracuse New York, Columbus Ohio, Dayton Ohio, Austin Texas, Green Bay Wisconsin, Mesa Arizona, Tampa Florida, Augusta Georgia, Savannah Georgia, Davenport Iowa, Sterling Heights Michigan, Michigan, Orem Utah, Provo Utah, Madison Wisconsin, Iowa City Iowa, Nampa Idaho, Kentucky, Lexington-Fayette Kentucky, Warren Michigan, Ann Arbor Michigan, Bellevue Nebraska, Albuquerque New Mexico, Cleveland Ohio, Racine Wisconsin, Wisconsin, Milwaukee Wisconsin, Scottsdale Arizona, Miami Florida, Georgia, Cedar Rapids Iowa 02/19/2025
- Provider Contracts Specialist Arizona, Miami Florida, Atlanta Georgia, Sterling Heights Michigan, Grand Island Nebraska, Idaho, Roswell New Mexico, Santa Fe New Mexico, Kentucky, Lexington-Fayette Kentucky, New York, Austin Texas, Salt Lake City Utah, Vancouver Washington, Tacoma Washington, Milwaukee Wisconsin, Phoenix Arizona, Warren Michigan, Columbus Georgia, Des Moines Iowa, Albuquerque New Mexico, Bowling Green Kentucky, Houston Texas, Chandler Arizona, St. Petersburg Florida, Louisville Kentucky, Detroit Michigan, Ann Arbor Michigan, Michigan, Las Cruces New Mexico, Nampa Idaho, Idaho Falls Idaho, Rochester New York, New York New York, Cedar Rapids Iowa, Iowa City Iowa, Kearney Nebraska, Lincoln Nebraska, Bellevue Nebraska, Iowa, Caldwell Idaho, New Mexico, Covington Kentucky, Syracuse New York, Cleveland Ohio, Texas, Bellevue Washington, Spokane Washington, Scottsdale Arizona, Jacksonville Florida, Florida, Augusta Georgia, Macon Georgia, Sioux City Iowa, Nebraska, Meridian Idaho, San Antonio Texas, Seattle Washington, Kenosha Wisconsin, Green Bay Wisconsin, Savannah Georgia, Yonkers New York, Ohio, Cincinnati Ohio, Akron Ohio, Dayton Ohio, Fort Worth Texas, Utah, Racine Wisconsin, Mesa Arizona, Tucson Arizona, Tampa Florida, Owensboro Kentucky, Omaha Nebraska, Rio Rancho New Mexico, West Valley City Utah, Washington, Orlando Florida, Grand Rapids Michigan, Georgia, Davenport Iowa, Boise Idaho, Buffalo New York, Columbus Ohio, Dallas Texas, Layton Utah, Provo Utah, Orem Utah, Wisconsin, Madison Wisconsin 02/19/2025
No recently viewed jobs.
View All JobsNo saved jobs.
View All Jobs