Detectives and Criminal Investigators

**JOB DESCRIPTION**

**Job Summary**

The SIU Coding Investigator is responsible for investigating and resolving instances of healthcare 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 contracts.

+ Devise clinical summary post review.

+ Communicate and participate in meetings related to cases.

+ Critical thinking, problem solving and analytical skills.

+ Ability to prioritize and manage multiple tasks.

+ Proven ability to work in a team setting.

+ 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/New York location

+ Thorough knowledge of PC based software including Microsoft Word (edit/save documents) and Microsoft Excel (edit/save spreadsheets, sort/filter)

**Required License, Certification, Association**

Licensed registered nurse (RN), Licensed practical nurse (LPN) and/or Certified Coder (CPC, CCS, and/or CPMA)

**Preferred Education**

Bachelor's degree (or higher)

**Preferred Experience**

+ 2+ years of experience working in the group health business preferred, particularly within claims processing or operations.

+ A demonstrated working knowledge of Local, State & Federal laws and regulations pertaining to health insurance, investigations & legal processes (Commercial insurance, Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, etc.)

+ Experience with UNET, Comet, Macess/CSP, or other similar claims processing systems.

+ Demonstrated ability to use MS Excel/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**

+ AAPC Certified Medical CPC, CPMA, CPCO or similar specialist preferred

+ Certified Fraud Examiner and/or AHFI professional designations preferred

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: $21.82 - $51.06 / HOURLY

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

**JOB DESCRIPTION**

**Job Summary**

The SIU Coding Investigator is responsible for investigating and resolving instances of healthcare 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 contracts.

+ Devise clinical summary post review.

+ Communicate and participate in meetings related to cases.

+ Critical thinking, problem solving and analytical skills.

+ Ability to prioritize and manage multiple tasks.

+ Proven ability to work in a team setting.

+ 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/New York location

+ Thorough knowledge of PC based software including Microsoft Word (edit/save documents) and Microsoft Excel (edit/save spreadsheets, sort/filter)

**Required License, Certification, Association**

Licensed registered nurse (RN), Licensed practical nurse (LPN) and/or Certified Coder (CPC, CCS, and/or CPMA)

**Preferred Education**

Bachelor's degree (or higher)

**Preferred Experience**

+ 2+ years of experience working in the group health business preferred, particularly within claims processing or operations.

+ A demonstrated working knowledge of Local, State & Federal laws and regulations pertaining to health insurance, investigations & legal processes (Commercial insurance, Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, etc.)

+ Experience with UNET, Comet, Macess/CSP, or other similar claims processing systems.

+ Demonstrated ability to use MS Excel/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**

+ AAPC Certified Medical CPC, CPMA, CPCO or similar specialist preferred

+ Certified Fraud Examiner and/or AHFI professional designations preferred

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: $21.82 - $51.06 / HOURLY

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

**JOB DESCRIPTION**

**Job Summary**

The SIU Coding Investigator is responsible for investigating and resolving instances of healthcare 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 contracts.

+ Devise clinical summary post review.

+ Communicate and participate in meetings related to cases.

+ Critical thinking, problem solving and analytical skills.

+ Ability to prioritize and manage multiple tasks.

+ Proven ability to work in a team setting.

+ 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/New York location

+ Thorough knowledge of PC based software including Microsoft Word (edit/save documents) and Microsoft Excel (edit/save spreadsheets, sort/filter)

**Required License, Certification, Association**

Licensed registered nurse (RN), Licensed practical nurse (LPN) and/or Certified Coder (CPC, CCS, and/or CPMA)

**Preferred Education**

Bachelor's degree (or higher)

**Preferred Experience**

+ 2+ years of experience working in the group health business preferred, particularly within claims processing or operations.

+ A demonstrated working knowledge of Local, State & Federal laws and regulations pertaining to health insurance, investigations & legal processes (Commercial insurance, Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, etc.)

+ Experience with UNET, Comet, Macess/CSP, or other similar claims processing systems.

+ Demonstrated ability to use MS Excel/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**

+ AAPC Certified Medical CPC, CPMA, CPCO or similar specialist preferred

+ Certified Fraud Examiner and/or AHFI professional designations preferred

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: $21.82 - $51.06 / HOURLY

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

**JOB DESCRIPTION**

**Job Summary**

The SIU Coding Investigator is responsible for investigating and resolving instances of healthcare 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 contracts.

+ Devise clinical summary post review.

+ Communicate and participate in meetings related to cases.

+ Critical thinking, problem solving and analytical skills.

+ Ability to prioritize and manage multiple tasks.

+ Proven ability to work in a team setting.

+ 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/New York location

+ Thorough knowledge of PC based software including Microsoft Word (edit/save documents) and Microsoft Excel (edit/save spreadsheets, sort/filter)

**Required License, Certification, Association**

Licensed registered nurse (RN), Licensed practical nurse (LPN) and/or Certified Coder (CPC, CCS, and/or CPMA)

**Preferred Education**

Bachelor's degree (or higher)

**Preferred Experience**

+ 2+ years of experience working in the group health business preferred, particularly within claims processing or operations.

+ A demonstrated working knowledge of Local, State & Federal laws and regulations pertaining to health insurance, investigations & legal processes (Commercial insurance, Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, etc.)

+ Experience with UNET, Comet, Macess/CSP, or other similar claims processing systems.

+ Demonstrated ability to use MS Excel/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**

+ AAPC Certified Medical CPC, CPMA, CPCO or similar specialist preferred

+ Certified Fraud Examiner and/or AHFI professional designations preferred

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: $21.82 - $51.06 / HOURLY

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

**JOB DESCRIPTION**

**Job Summary**

The SIU Coding Investigator is responsible for investigating and resolving instances of healthcare 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 contracts.

+ Devise clinical summary post review.

+ Communicate and participate in meetings related to cases.

+ Critical thinking, problem solving and analytical skills.

+ Ability to prioritize and manage multiple tasks.

+ Proven ability to work in a team setting.

+ 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/New York location

+ Thorough knowledge of PC based software including Microsoft Word (edit/save documents) and Microsoft Excel (edit/save spreadsheets, sort/filter)

**Required License, Certification, Association**

Licensed registered nurse (RN), Licensed practical nurse (LPN) and/or Certified Coder (CPC, CCS, and/or CPMA)

**Preferred Education**

Bachelor's degree (or higher)

**Preferred Experience**

+ 2+ years of experience working in the group health business preferred, particularly within claims processing or operations.

+ A demonstrated working knowledge of Local, State & Federal laws and regulations pertaining to health insurance, investigations & legal processes (Commercial insurance, Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, etc.)

+ Experience with UNET, Comet, Macess/CSP, or other similar claims processing systems.

+ Demonstrated ability to use MS Excel/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**

+ AAPC Certified Medical CPC, CPMA, CPCO or similar specialist preferred

+ Certified Fraud Examiner and/or AHFI professional designations preferred

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: $21.82 - $51.06 / HOURLY

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

Description

The Special Projects & Investigations team is looking for an experienced, motivated industry specialist with background in risk, digital fraud, compliance, or cyber investigations who also have advanced data analysis skills (SQL, Python, Machine Learning, Data Science). This role will manage critical and high impact projects and scale their findings through technology and analytics to interpret risks across Amazon’s entire business segment or apply other industry experience to develop feasible, systematic solutions to endemic problems.

The Customer Trust (CT) organization's mission is to keep Amazon stores safe and trustworthy for our buyers, brands and selling partners, by enabling our selling partners to provide great CX while ensuring bad actors are kept out of our stores. The Special Projects & Investigations (SPI) team protects Amazon’s WW stores store by creating projects and programs focused on the detection of abuse at its earliest point and identifying the root causes, vulnerabilities or exploits to systematically address to prevent future abuse. We search out highly skilled candidates who move fast, have an entrepreneurial spirit to create new solutions, a tenacity to get things done, thrive in an environment of ambiguity and change, and are capable of breaking down and solving complex problems. We value individual expression, respect different opinions, and work together to create a culture where each of us is able to contribute fully. The combination of our unique backgrounds and perspectives strengthens our ability to achieve Amazon's mission of being Earth's most customer-centric company.

We catch bad actors and stop online fraud. It’s fun. It’s hard. It matters. We are passionate about protecting our selling partners and customers from bad actors and want a candidate that shares that passion. Amazon is one of the world’s most trusted companies. Help us keep it that way. To achieve this, the ideal candidate should be passionate about use of advanced data analytics and technology approaches to identify patterns and establish connections to uncover process and technology gaps and prevent fraud across Amazon stores worldwide. Your decisions are not only fundamental to helping protect customers and selling partners but will help maintain the health of Amazon’s catalog and product listings ecosystem.

Key job responsibilities

• Complete risk analyses and manipulate data in complex data sets (SQL, Python, R etc.)

• Use high-level judgment to inform our most complex enforcement decisions

• Identify gaps and risks in Amazon's current mechanisms and policies and recommend solutions to product/policy owning teams.

• Use data and/or technical skills to discover new ways to scale deep dive signals resulting in the identification of many bad actors and sizing the issue

• Owning the complete life cycle of one or more complex problems - from identification through scaling the solutions

• Break problems into manageable pieces, ruthlessly prioritizing, and delivering results in an ambiguous environment

• Conduct large scale deep dives to derive insights about tactics used to conduct abuse on our stores, identifying gaps and risk in Amazon's current mechanisms, systems, and policies

• Write documents for partner teams and executives that identify problems, propose technical solutions, and drive alignment among stakeholders

• Own partnerships with stakeholder teams and guide appropriate trade-offs, clearly communicate goals, roles and responsibilities.

A day in the life

Your day might involve diving deep into data to uncover emerging fraud patterns, collaborating with teams across Amazon to implement protective solutions, or developing new detection methods. You'll balance independent analytical work with team collaboration, sharing insights and supporting colleagues in our shared mission.

About the team

Our team is comprised of practitioners of fraud and abuse, working to understand bad actor ecosystems using threat intelligence analytics and technical skills. We complement specialized industry skills with broad risk experiences, to deliver results - we wear a lot of hats and take ownership of hard to solve problem areas whenever possible. We speak 12 languages, write code in 3 (mostly self-taught, on the job), and celebrate learning and taking risks. We encourage experimentation and curiosity while supporting each other to constantly learn and grow.

Our work is to solve hard puzzles and identify what hasn’t already been discovered - typically with data and always with a lot persistence and curiosity. If you like the sound of that, come join us.

Basic Qualifications

• Bachelor’s or postgraduate degree in Information Security, Computer Science, Data Science/Analytics, Engineering, Mathematics, Statistics or related discipline.

• 3+ years of relevant industry experience in risk or fraud investigations, regulatory compliance, ecommerce, analytics, or security

• Proficient with deriving insights from big data using SQL & experience manipulating/processing data with Python

• Proven ability to deliver complex projects across multiple teams

Preferred Qualifications

• Experience working in e-commerce organizations

• Experience working within fraud, compliance, law enforcement, or intelligence organizations

• Experience with AWS services like Redshift, Neptune or Sagemaker

• Masters degree in or practical experience with data science or machine learning

• Excellent written and verbal communication skills to communicate security and business risk to a broad range of technical and non-technical audiences.

• High level of integrity and discretion to handle confidential information.

• Exceptional ownership and bias for action: willing to move quickly and decisively

• Proven ability to problem solve in large/complex/technical systems

Amazon is an equal opportunity employer and does not discriminate on the basis of protected veteran status, disability, or other legally protected status.

Our inclusive culture empowers Amazonians to deliver the best results for our customers. If you have a disability and need a workplace accommodation or adjustment during the application and hiring process, including support for the interview or onboarding process, please visit https://amazon.jobs/content/en/how-we-hire/accommodations for more information. If the country/region you’re applying in isn’t listed, please contact your Recruiting Partner.

Our compensation reflects the cost of labor across several US geographic markets. The base pay for this position ranges from $91,800/year in our lowest geographic market up to $196,300/year in our highest geographic market. Pay is based on a number of factors including market location and may vary depending on job-related knowledge, skills, and experience. Amazon is a total compensation company. Dependent on the position offered, equity, sign-on payments, and other forms of compensation may be provided as part of a total compensation package, in addition to a full range of medical, financial, and/or other benefits. For more information, please visit https://www.aboutamazon.com/workplace/employee-benefits . This position will remain posted until filled. Applicants should apply via our internal or external career site.

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

**Position Summary**

The Certified Professional Coder (CPC) will perform medical claim reviews to ensure compliance with coding practices through a comprehensive record review for medical, behavioral, transportation and other healthcare providers. The CPC must have the ability to determine correct coding and appropriate documentation during the review of medical records. The CPC must also ensure that the state, federal and company requirements are met and recognize any concerning billing patterns or trends.

Activities include:

- Conduct a comprehensive medical record review to ensure billing is consistent with medical record.

- Provide detailed written summary of medical record review findings.

- Must be able to articulate findings to investigators, Medicaid plan leadership, law enforcement, legal counsel, providers, state regulators, etc.

- Review and discuss cases with Medical Directors to validate decisions.

- Assist with investigative research related to coding questions, state and federal policies.

- Identify potential billing errors, abuse, and fraud.

- Identify opportunities for savings related to potential cases which may warrant a prepayment review.

- Maintain appropriate records, files, documentation, etc.

- Ability to travel for meetings and potential to testify

**Required Qualifications**

- AAPC Coding certification - Certified Professional Coder (CPC)

- 3+ years of experience in medical coding or documentation auditing.

- Strong knowledge of standard industry coding guides and guidelines including CPT, HCPCS, ICD-10, CMS 1500 and UB04 data elements

- Experience with researching coding, state regulations and policies.

- Working experience with Microsoft Excel

**Preferred Qualifications**

- 2 years or more previous experience with Behavioral Health coding/auditing of records

- Licensed Clinical Social Worker (LCSW)

- Licensed Independent Social Worker (LISW)

- Licensed Master Social Worker (LMSW)

- Prior auditing experience

- Excellent analytical skills

- Strong attention to detail and ability to review and interpret data

- Excellent communication skills

**Education**

- GED or equivalent

- AAPC Certified Professional Coder Certification (CPC)

**Anticipated Weekly Hours**

40

**Time Type**

Full time

**Pay Range**

The typical pay range for this role is:

$43,888.00 - $102,081.00

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

**Great benefits for great people**

We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

+ **Affordable medical plan options,** a **401(k) plan** (including matching company contributions), and an **employee stock purchase plan** .

+ **No-cost programs for all colleagues** including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.

+ **Benefit solutions that address the different needs and preferences of our colleagues** including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 07/11/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

**Why USAA?**

At USAA, our mission is to empower our members to achieve financial security through highly competitive products, exceptional service and trusted advice. We seek to be the #1 choice for the military community and their families.

Embrace a fulfilling career at USAA, where our core values – honesty, integrity, loyalty and service – define how we treat each other and our members. Be part of what truly makes us special and impactful.

**The Opportunity**

As a dedicated Director of a Special Investigations Unit, you will be responsible for the Claims fraud investigation strategy, program management, regional management of investigative staff and the results achieved. You will develop investigative and other operational priorities, manages workload balance, develops staffing strategies, and evaluates operational results. You will ensure compliance with policies and procedures contributing to fraud control objectives, as well as compliance with state insurance fraud-related laws and regulations.

We offer a flexible work environment that requires an individual to be in the office 4 days per week. This position can be based in one of the following locations: Phoenix, AZ, Tampa, FL or San Antonio, TX.

Relocation assistance is not available for this position.

What you'll do:

+ Develop investigative and other operational priorities, manages workload balance, develops staffing strategies, and evaluates operational results.

+ Create and maintain industry and other business relationships.

+ Direct claims investigative teams, ensure business performance and progress towards short- and long-term objectives.

+ Develop and implement Claims Security operational plans/policies in conjunction with senior leadership.

+ Consult with senior leadership on strategic direction for SIU.

+ Identify emerging trends and develops new investigation programs and processes.

+ Be responsible for communication and training tactics in support of new programs and processes.

+ Regularly interact with and influence peers and executive management on significant operational issues.

+ Be responsible for measuring and reporting on business outcomes for SIU strategy.

+ Develop collaborative internal and external relationships with enterprise business partners, vendors, and industry groups.

+ Coordinate Claims Security Quality Assurance program.

+ Be responsible for hiring, employee development, coaching, counseling, performance evaluation and all leadership and management related functions.

+ Ensure risks associated with business activities are effectively identified, measured, monitored, and controlled in accordance with risk and compliance policies and procedures.

What you have:

+ Bachelor’s degree: OR 4 years of related experience (in addition to the minimum years of experience required) may be substituted in lieu of degree.

+ 8 years of progressive related experience (i.e., claims, law enforcement, etc.) or 6 years of P&C experience plus military service experience.

+ 3 years of direct team lead or management experience.

+ Demonstrated team leadership, cross-functional collaboration, building business solutions, and/or claims/investigation accountabilities.

+ Experience using, interpreting, solutioning and leading with data.

+ Proficiency at investigative protocols and procedures that would include compliant claims or fraud investigations to the specific state and regulatory requirements.

+ Possess in-depth knowledge of insurance policies and broad understanding of procedures related to SIU investigations.

+ Capability to analyze data, conduct root causes analysis, identify root causes, and recommend action plans and strategies to overcome operational obstacles and achieve strategic targets.

+ Ability to act as a subject matter expert to the claims organization to provide guidance and advice on a wide range of fraud related risk and communicating effective courses of action.

+ Skilled at presenting business recommendations in a professional format.

What sets you apart:

+ Proven experience leading a Special Investigations Unit (SIU) program.

+ Strong understanding of advanced fraud analytics principles and methodologies.

+ Demonstrated project management experience, with a track record of successful project completion.

+ Experience managing and developing people leaders within Law Enforcement, Claims, or SIU environments.

+ Established and extensive professional network within the Property & Casualty (P&C) insurance industry.

+ In-depth knowledge of Property Claims processes, regulations, and best practices.

+ Exceptional communication (both written and verbal), interpersonal, and problem-solving skills.

+ Demonstrated analytical and decision-making skills, with the ability to make sound judgments under pressure and within required timeframes.

+ Advanced knowledge of SIU investigations, encompassing both Express and Core investigation types.

+ Proven ability to influence stakeholders across business units to champion and drive strategic initiatives.

Compensation range: The salary range for this position is: $127,310 - $243,340.

USAA does not provide visa sponsorship for this role. Please do not apply for this role if at any time (now or in the future) you will need immigration support (i.e., H-1B, TN, STEM OPT Training Plans, etc.).

**Compensation:** USAA has an effective process for assessing market data and establishing ranges to ensure we remain competitive. You are paid within the salary range based on your experience and market data of the position. The actual salary for this role may vary by location.

Employees may be eligible for pay incentives based on overall corporate and individual performance and at the discretion of the USAA Board of Directors.

The above description reflects the details considered necessary to describe the principal functions of the job and should not be construed as a detailed description of all the work requirements that may be performed in the job.

**Benefits:** At USAA our employees enjoy best-in-class benefits to support their physical, financial, and emotional wellness. These benefits include comprehensive medical, dental and vision plans, 401(k), pension, life insurance, parental benefits, adoption assistance, paid time off program with paid holidays plus 16 paid volunteer hours, and various wellness programs. Additionally, our career path planning and continuing education assists employees with their professional goals.

For more details on our outstanding benefits, visit our benefits page on USAAjobs.com.

_Applications for this position are accepted on an ongoing basis, this posting will remain open until the position is filled. Thus, interested candidates are encouraged to apply the same day they view this posting._

_USAA is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran._

**If you are an existing USAA employee, please use the internal career site in OneSource to apply.**

**Please do not type your first and last name in all caps.**

**_Find your purpose. Join our mission._**

USAA is unlike any other financial services organization. The mission of the association is to facilitate the financial security of its members, associates and their families through provision of a full range of highly competitive financial products and services; in so doing, USAA seeks to be the provider of choice for the military community. We do this by upholding the highest standards and ensuring that our corporate business activities and individual employee conduct reflect good judgment and common sense, and are consistent with our core values of service, loyalty, honesty and integrity.

USAA attributes its long-standing success to its most valuable resource: our 35,000 employees. They are the heart and soul of our member-service culture. When you join us, you'll become part of a thriving community committed to going above for those who have gone beyond: the men and women of the U.S. military, their associates and their families. In order to play a role on our team, you don't have to be connected to the military yourself – you just need to share our passion for serving our more than 13 million members.

USAA is an EEO/AA Employer - applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, disability, genetic information, sexual orientation, gender identity or expression, pregnancy, protected veteran status or other status protected by law.

California applicants, please review our HR CCPA - Notice at Collection (https://statmcstg.usaa.com/mcontent/static\_assets/Media/enterprise\_hr\_cpra\_notice\_at\_collection.pdf) here.

USAA is an EEO/AA Employer - applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, disability, genetic information, sexual orientation, gender identity or expression, pregnancy, protected veteran status or other status protected by law.

At U.S. Bank, we’re on a journey to do our best. Helping the customers and businesses we serve to make better and smarter financial decisions and enabling the communities we support to grow and succeed. We believe it takes all of us to bring our shared ambition to life, and each person is unique in their potential. A career with U.S. Bank gives you a wide, ever-growing range of opportunities to discover what makes you thrive at every stage of your career. Try new things, learn new skills and discover what you excel at—all from Day One.

**Job Description**

External Fraud Investigators may concentrate on one specific or many different fraud typologies such as external fraud, elder and vulnerable adult financial exploitation, technology related fraud, organized fraud rings and anti-money laundering depending on business needs within Fraud Investigations. External Fraud Investigators perform duties such as investigating multiple fraud typologies in accordance with policies and procedures, performing thorough account transaction analysis for the purpose of identifying suspicious or fraudulent activity, and filing Suspicious Activity Reports (SARs). An investigator may review consumer and commercial DDAs, loans, lines of credit, debit and credit cards, technology products and investment products.

Maintain thorough and accurate case notes setting forth all required actions in chronological order through utilization of a case management system.

Conduct and documenting interviews with witnesses, victims and subjects as appropriate.

Report investigative findings to the appropriate designee within Fraud Investigations with recommendation for SAR or no SAR Determination.

Prepare complete and accurate SARs for filing.

Ability to correctly identify when matters are appropriate to escalate to management and/or to law enforcement.

Ensure case accurate case completion for all case resolutions prior to submission to appropriate designee within Fraud Investigations for case closure approval.

Participation and compliance with internal continuing education and training. Training topics may include: Compliance with the U.S. Bank Code of Ethics and all Anti-Money Laundering, Bank Secrecy Act, information security and suspicious activity reporting requirements, policies and procedures. Participation in any required corporate and business line training in these areas. Understanding and adherences to internal suspicious activity referral requirements and processes as required for this position.

**Preferred Qualifications**

+ Bachelor's degree, or equivalent work experience

+ 2-3 years of experience in an applicable risk management environment

+ Certified Fraud Examiner (CFE) or other professional fraud certification

+ Experience interviewing suspects and/or victims

**Preferred Skills/Experience**

+ SAR writing and quality assurance experience

+ Prior investigation experience

+ Prior law enforcement experience

+ Prior financial/banking sector experience

+ Prior accounting/auditing experience

+ Computer/digital forensic skills

+ Strong analytical skills

+ Strong proficiency in MS-Excel and MS-Word

+ Excellent written and verbal communication skills

+ Ability to maintain high levels of confidentiality and data security standards.

+ Ability to handle multiple complex assignments concurrently

+ Strong time management skills and high degree of initiative

+ Demonstrated positive attitude with results orientation

+ Proven track record of meeting tight deadlines

+ Experience/comfort in working through change

**_*The role offers a hybrid/flexible schedule, which means there's an in-office expectation of 3 or more days per week and the flexibility to work outside the office location for the other days._**

If there’s anything we can do to accommodate a disability during any portion of the application or hiring process, please refer to our disability accommodations for applicants (https://careers.usbank.com/global/en/disability-accommodations-for-applicants) .

**Benefits:**

Our approach to benefits and total rewards considers our team members’ whole selves and what may be needed to thrive in and outside work. That's why our benefits are designed to help you and your family boost your health, protect your financial security and give you peace of mind. Our benefits include the following (some may vary based on role, location or hours):

+ Healthcare (medical, dental, vision)

+ Basic term and optional term life insurance

+ Short-term and long-term disability

+ Pregnancy disability and parental leave

+ 401(k) and employer-funded retirement plan

+ Paid vacation (from two to five weeks depending on salary grade and tenure)

+ Up to 11 paid holiday opportunities

+ Adoption assistance

+ Sick and Safe Leave accruals of one hour for every 30 worked, up to 80 hours per calendar year unless otherwise provided by law

U.S. Bank is an equal opportunity employer. We consider all qualified applicants without regard to race, religion, color, sex, national origin, age, sexual orientation, gender identity, disability or veteran status, and other factors protected under applicable law.

**E-Verify**

U.S. Bank participates in the U.S. Department of Homeland Security E-Verify program in all facilities located in the United States and certain U.S. territories. The E-Verify program is an Internet-based employment eligibility verification system operated by the U.S. Citizenship and Immigration Services. Learn more about the E-Verify program (https://careers.usbank.com/verification-of-eligibility-for-employment) .

The salary range reflects figures based on the primary location, which is listed first. The actual range for the role may differ based on the location of the role. In addition to salary, U.S. Bank offers a comprehensive benefits package, including incentive and recognition programs, equity stock purchase 401(k) contribution and pension (all benefits are subject to eligibility requirements). Pay Range: $66,640.00 - $78,400.00 - $86,240.00

U.S. Bank will consider qualified applicants with arrest or conviction records for employment. U.S. Bank conducts background checks consistent with applicable local laws, including the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act as well as the San Francisco Fair Chance Ordinance. U.S. Bank is subject to, and conducts background checks consistent with the requirements of Section 19 of the Federal Deposit Insurance Act (FDIA). In addition, certain positions may also be subject to the requirements of FINRA, NMLS registration, Reg Z, Reg G, OFAC, the NFA, the FCPA, the Bank Secrecy Act, the SAFE Act, and/or federal guidelines applicable to an agreement, such as those related to ethics, safety, or operational procedures.

Applicants must be able to comply with U.S. Bank policies and procedures including the Code of Ethics and Business Conduct and related workplace conduct and safety policies.

**Posting may be closed earlier due to high volume of applicants.**

**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 draw conclusions on allegations of FWA and/or may determine appropriateness of care. 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 Officers in order to achieve and maintain appropriate anti-fraud oversight.

**Job Duties**

+ Responsible for developing leads presented to the SIU to assess and determine whether potential fraud, waste, or abuse is corroborated by evidence.

+ Conducts both preliminary assessments of FWA allegations, and end to end full investigations, including but not limited to witness interviews, background checks, data analytics to identify outlier billing behavior, contract and program regulation research, provider and member education, findings identification and communications development, and recommendations and preparation of overpayment identifications and closure of investigative cases.

+ Completes investigations within the mandated period of time required by either state and/or federal contracts and/or regulations.

+ Conducts both on-site and desk top investigations.

+ Conducts low to medium, and extensive investigations, including reviews of medical records and data analysis, and makes determinations as to whether the investigation and/or audit identified potential fraud, waste, or abuse.

+ Coordinates with various internal customers (e.g., Provider Services, Contracting and Credentialing, Healthcare Services, Member Services, Claims) to gather documentation pertinent to investigations.

+ Detects potential health care fraud, waste, and abuse through the identification of aberrant coding and/or billing patterns through utilization review.

+ Prepares appropriate FWA referrals to regulatory agencies and law enforcement.

+ Documents appropriately all case related information in the case management system in an accurate manner, including storage of case documentation following SIU related requirements. 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.

+ Renders provider education on appropriate practices (e.g., coding) as appropriate based on national or local guidelines, contractual, and/or regulatory requirements.

+ Interacts with regulatory and/or law enforcement agencies regarding case investigations.

+ Prepares audit results letters to providers when overpayments are identified.

+ Works may be remote, in office, and on-site travel within the state of New York as needed.

+ Ensures compliance with applicable contractual requirements, and federal and state regulations.

+ Complies with SIU Policies as and procedures as well as goals set by SIU leadership.

+ Supports SIU in arbitrations, legal procedures, and settlements.

+ Actively participates in MFCU meetings and roundtables on FWA case development and referral

**JOB QUALIFICATIONS**

**Required Education**

Bachelors degree or Associate’s Degree, in criminal justice or equivalent combination of education and experience

**REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES**

+ 1-3 years of experience, unless otherwise required by state contract

+ Proven investigatory skill; ability to organize, analyze, and effectively determine risk with corresponding solutions; ability to remain objective and separate facts from opinions.

+ Knowledge of investigative and law enforcement procedures with emphasis on fraud investigations.

+ Knowledge of Managed Care and the Medicaid and Medicare programs as well as Marketplace.

+ Understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems.

+ Understanding of datamining and use of data analytics to detect fraud, waste, and abuse.

+ Proven ability to research and interpret regulatory requirements.

+ Effective interpersonal skills and customer service focus; ability to interact with individuals at all levels.

+ Excellent oral and written communication skills; presentation skills with ability to create and deliver training, informational and other types of programs.

+ Advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook), SharePoint and Intra/Internet as well as proficiency with incorporating/merging documents from various applications.

+ Strong logical, analytical, critical thinking and problem-solving skills.

+ Initiative, excellent follow-through, persistence in locating and securing needed information.

+ Fundamental understanding of audits and corrective actions.

+ Ability to multi-task and operate effectively across geographic and functional boundaries.

+ Detail-oriented, self-motivated, able to meet tight deadlines.

+ Ability to develop realistic, motivating goals and objectives, track progress and adapt to changing priorities.

+ Energetic and forward thinking with high ethical standards and a professional image.

+ Collaborative and team-oriented

**REQUIRED LICENSE, CERTIFICATION, ASSOCIATION** :

+ Valid driver’s license required.

**PREFERRED EXPERIENCE** :

At least 5 years of experience in FWA or related work.

**PREFERRED LICENSE, CERTIFICATION, ASSOCIATION** :

+ Health Care Anti-Fraud Associate (HCAFA).

+ Accredited Health Care Fraud Investigator (AHFI).

+ Certified Fraud Examiner (CFE).

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: $21.82 - $51.06 / HOURLY

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