Establish a specifically designed compliance program that effectively prevents and/or detects violation of applicable laws and regulations, which will protect the Business from liability of fraudulent or abusive practices. Ensures that the Business understands and complies with applicable laws and regulations pertaining to the Health Care environment. Ensures the Business' accountability for compliance by overseeing, follow-up and resolution of investigations.
• Responsible for referral intake process and developing leads presented to the SIU to assess and determine whether potential fraud, waste, or abuse is corroborated by evidence.
• Conducts preliminary investigations, along with witness interviews, within the mandated period of time required by either state and/or federal contracts and/or regulations.
• Conducts non-medical/non-coding related extensive investigations and makes determinations as to whether the investigation and/oraudit identified potential fraud, waste, or abuse.
• Prepares detailed preliminary and extensive investigation referrals to state and/or federal regulatory and/or law enforcement agencies when potential fraud, waste, or abuse is identified as required by regulatory and/or contract requirements.
• Interacts with regulatory and/or law enforcement agencies regarding case investigations.
• Conducts detailed claims analysis and prepares audit results letters to providers when overpayments are identified.
Associate's Degree or equivalent combination of education and experience
Bachelor's Degree or equivalent work experience.
Preferred License, Certification, Association
• Health Care Anti-Fraud Associate (HCAFA)
• Accredited Health Care Fraud Investigator (AHFI)
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.
Apply on company website