Private Detectives and Investigators

**About the Role**

Uber is a technology company that is changing the way the world thinks about transportation. Whether it's heading home from work, getting a meal delivered from a favorite restaurant, or a way to earn extra income, Uber is becoming part of the fabric of daily life. We're making cities safer, smarter, and more connected.

As **Senior Manager, Special Investigations and Insurance Fraud** , you will be a pivotal player in shaping and optimizing Uber's insurance fraud strategy through data-driven insights. You and your team will be key members of the growing **US&C Claims** team, operating as a senior manager and reporting to the **Director, Claims Services** . Your expertise will be crucial in leading efforts around Carriers, Major case investigation, fraud operations team.

While a background in Special Investigations is important, this role also emphasizes strong analytical skills and the ability to leverage data to drive strategic decisions. We're looking for a highly influential and proactive leader who is detail-oriented, moves with pace, and is capable of driving significant change to reduce the cost of insurance through identifying fraud, and taking action to eliminate or mitigate the impact thus continuing to keep Safety First. The ideal candidate has a strong understanding of the role of claims and fraud investigations within the insurance ecosystem, proven experience in developing and utilizing claims reporting and analytics, and is ready to "go get it." This role requires someone who can shape strategy, think big, and understand detail (#SeeTheForestAndTheTrees), all while operating with a high level of autonomy.

Uber embraces a hybrid work model, where employees are in office three days a week. This approach promotes a balanced and productive work environment that accommodates both individual preferences and organizational needs.

What You'll Do

+ **SIU/Fraud Parternships:** Serve as the primary point of contact for all external claims SIU partners - Carrier SIU teams, industry groups such as NICB and the Coalition Against Insurance Fraud, and various law enforcement agencies.

+ **Major Case Investigations:** Drive claims outcomes on major case investigations, including EUO and litigation support. Leverage claims expertise and advanced analytical capabilities to identify complex relationships and fraud schemes. Utilize data visualization tools to effectively communicate complex data findings.

+ **Operational Performance and Collaboration:** Develop, implement, and monitor operational health metrics and key performance indicators (KPIs) in collaboration with internal investigations and carrier partner SIU teams. Provide regular updates to key stakeholders, highlighting trends and areas for improvement. Provide expert consultation to external insurance partners on data and reporting best practices, and collaborate on data-driven performance improvement initiatives. Provide data-driven input into the design, documentation, and deployment of SIU processes, ensuring alignment with the various stakeholders.

+ **Fraud Operations:** Manage the fraud operations team responsible for responding to carrier partner SIU inquiries, drive investigation and outcomes on non-major case issues including account review and actioning.

Basic Qualifications

+ 8+ years of experience in Claims and/or Fraud Investigations.

Preferred Qualifications

+ 5+ years experience leading claims or fraud teams

+ Experience managing complex investigations and supporting various forms of fraud related litigation.

+ **Analytical and Data Strategy Expertise:** Deep familiarity with designing, developing, and utilizing claims-related data, reporting, and analytics; proven experience in developing and implementing fraud strategies, including tool selection and vendor management; able to understand and interpret complex metrics and KPIs.

+ **Influence, Communication, and Collaboration:** Exceptional ability to influence stakeholders at all levels, build strong relationships with internal and external partners, and adapt presentations and messaging to different levels of audience, from individual contributors to senior executive leaders.

+ **Strategic Thinking and Execution:** Proven ability to shape strategy, think big, and understand detail, demonstrating a balance of strategic vision and tactical execution; strong attention to detail while maintaining a fast pace to deliver high-quality results efficiently; highly independent and proactive, with a strong understanding of industry trends and a passion for leveraging data to drive change.

+ **Change Management Expertise:** Significant experience driving major change across large, complex organizations.

For Chicago, IL-based roles: The base salary range for this role is USD$162,000 per year - USD$180,000 per year. For New York, NY-based roles: The base salary range for this role is USD$180,000 per year - USD$200,000 per year. For Phoenix, AZ-based roles: The base salary range for this role is USD$144,000 per year - USD$160,000 per year. For San Francisco, CA-based roles: The base salary range for this role is USD$180,000 per year - USD$200,000 per year. For all US locations, you will be eligible to participate in Uber's bonus program, and may be offered an equity award & other types of comp. You will also be eligible for various benefits. More details can be found at the following link https://www.uber.com/careers/benefits.

Uber is proud to be an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected Veteran status, age, or any other characteristic protected by law. We also consider qualified applicants regardless of criminal histories, consistent with legal requirements. If you have a disability or special need that requires accommodation, please let us know by completing this form- https://docs.google.com/forms/d/e/1FAIpQLSdb_Y9Bv8-lWDMbpidF2GKXsxzNh11wUUVS7fM1znOfEJsVeA/viewform

The City of Chandler Police Department, Intelligence Analysis Unit, is currently seeking qualified individuals interested in joining our team as an Investigative Analyst. This is a full-time, non-exempt position with benefit. The Investigative Analysts work a 4/10 schedule but may be required to work various schedules which include days, swings, nights, weekends and holidays. The position is regular full-time, subject to a six (6) month probationary period.

Why work for Chandler?

* Diverse and inclusive environment
* Up to 8 hours paid time off annually to volunteer in the community
* Dress code is business casual, with jeans on Fridays
* 3 medical plans to choose from along with dental and vision coverage
* Accrue 122 hours paid vacation in your first year, eligible for use immediately following accrual
* Accrue 96 hours paid sick leave in your first year, eligible for use immediately following accrual
* 12 paid holidays per year, plus Winter Break at the end of the year
* Become part of the Arizona State Retirement System with a 100% city contribution match
* City contributions of 1% gross wages per pay period to deferred compensation
* Robust Employee Wellness program with $350 incentive
* Professional development opportunities
* Tuition reimbursement up to $5,250 annually, $3,200 for part-time employees
* Free Tumbleweed Recreation Center membership

Who we are

The City of Chandler Police Department, consisting of 362 sworn officers and 177 civilians, serves a growing population of close to 287,945 residents. The organization is divided into three main divisions, one bureau, and many sections/units. The Patrol Operations Division consisting of three precincts, 1) Main Station - Downtown & North Chandler, 2) Desert Breeze - West Chandler, and 3) Chandler Heights - South Chandler, work in concert with the Criminal Investigations Division, Operational Support Division, and Professional Services Division to meet the needs of the community. The members of the Chandler Police Department are dedicated to the advancement of community policing and the development of a partnership with our citizens. Our mission is, “To maintain a safe, vibrant community through meaningful engagement and continuous organizational improvement.” We are committed to being a world-class leader in law enforcement. We will pursue and engage the best trained, equipped, and committed professionals who demonstrate the highest standards of performance and best policing practices in partnership with the community.

Who we are looking for

Our ideal candidate will have a passion for customer service, teamwork, and collaboration. This role performs non-sworn investigative duties in support of police criminal investigations including performing background research regarding criminal histories and searching linkages among people, cars, and homes to assist detectives and officers. We are looking for an individual who enjoys working in a fast-paced environment; and, the successful candidate must be able to do the following:

* Collect, compile, and organize criminal intelligence information; generates intelligence data for support in investigations; reads and records various intelligence, analytical and administrative information.
* Prepare and deliver clear, concise intelligence products including bulletins, briefings, charts, and reports for department personnel and partner agencies
* Work directly with detectives and patrol officers to research, analyze, evaluate and correlate criminal intelligence information; determines source reliability, content and validity; develops investigative leads and links
* Assist in the coordination of major investigations; prioritizes data; conducting analysis; analyzes call-logs.
* Provide exceptional customer service and responds to internal and external inquiries.
* Update and maintain law enforcement databases/records.
* Make appropriate recommendations for improvement in intelligence analysis practices and procedures.

To view the complete job description, please click here.

Minimum qualifications

* Must possess a High School or GED equivalency.
* Must have 4-years of previous experience related to area of assignment, or
* Any equivalent combination of experience and training which provides the knowledge and abilities necessary to perform the work.
* Must possess a valid Arizona driver’s license, with an acceptable driving record
* Must be able to obtain a DPS Level B Terminal Operator Certification within 6 months of hire.

Desired qualifications

* Associates degree is preferred

Supervision

Work is performed under the direct supervision of a civilian supervisor or Police Sergeant. This position does not supervise others.

Application Process

* NeoGov Application
* Spark Hire Virtual Interviews
* Preliminary Background Questionnaire Submittal & Review
* Oral Board Interview
* Background Interview
* Interview with Chief of Police

This is a full-time, non-exempt position with benefits, with a varied work schedule. A register of qualified candidates will be active for 4 months should another position become available.

The City of Chandler will conduct a pre-employment background check as a condition of employment. An offer of employment is contingent upon acceptable results. All applicants hired will be required to be fingerprinted with successful results as a condition of continued employment.

Applicants for employment and volunteer opportunities should be aware of the City of Chandler’s policies concerning the use of drugs and alcohol. These policies have not been altered by the passage of Proposition 207. The use of recreational marijuana is a violation of the city’s Drug Free Workplace Policy. Certain positions within the city are required to submit to a pre-employment drug test. A positive result for drugs tested under the policy, including recreational marijuana, may be grounds for withdrawal of an offer of employment or volunteer opportunity. The examination process may vary if determined necessary.

**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 make medical determinations as necessary, and applies clinical knowledge to assess the medical necessity, level of services, and/or appropriateness of care in cases. 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 Affairs, in order to achieve and maintain appropriate anti-fraud oversight.

**Job Duties**

• Perform objective desk and onsite medical record audits to verify if services were supported by documentation, to determine if services were appropriately administered, and/or to validate coding/billing accuracy.

• Conduct interviews of providers and/or health plan members in order to determine whether fraud, waste, or abuse may have occurred.

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

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

• Incorporate leadership and communication skills to work with physicians and other health professionals when investigating cases.

• Generate and provide accurate and timely written reports for internal and/external use detailing audit findings.

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

• Identify opportunities for improvement through the audit process and provide recommendations for system enhancement in order to augment investigative outcomes and performance.

**JOB QUALIFICATIONS**

**REQUIRED EDUCATION** :

Graduate from an Accredited School of Nursing.

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

+ Five years clinical nursing experience with broad clinical knowledge.

+ Five years experience conducting medical review and coding/billing audits involving professional and facility based services.

+ Knowledge and understanding of medical terminology along with demonstrated knowledge of CPT, ICD-9, HCPCS and DRG requirements.

+ Two years of managed care experience.

**REQUIRED LICENSE, CERTIFICATION, ASSOCIATION** :

Active, unrestricted State Registered Nursing (RN) license in good standing.

**PREFERRED EDUCATION** :

Bachelor’s Degree in Nursing

**PREFERRED EXPERIENCE** :

+ Experience in government programs (i.e., Medicare, Medicaid, & SCHIP).

+ Experience in long-term care.

**STATE SPECIFIC REQUIREMENTS** :

OHIO:

+ Transitions of Care for New Members

+ Molina Healthcare of Ohio follows the transition of care requirements outlined below and in Appendix D of the contract for new members transitioning to the MCO from fee-for-service (FFS) or another MCO. The Transition of Care Coach will coordinate all services with new members to ensure a seamless transition and ensure continuity of care.

+ Provision of Member Information

+ Pre-Enrollment Planning

+ The Molina Transition of Care Coach coordinates with and utilizes data provided by ODM, another MCO, the OhioRISE Plan (when applicable) and or collected by Molina (e.g. through assessments, new member outreach in advance of the member’s enrollment effective date) to identify existing sources of care and to ensure each new member is able to continue to receive existing services without disruption.

+ For OhioRISE Plan enrolled members, Molina will reach out to the OhioRISE Plan and primary care coordination staff to engage the OhioRISE Plan in pre-enrollment planning

+ Continuation of Services for Members

+ Documentation of Transition of Services

+ Transitions of Care Between Health Care Settings

+ Transitions of Care Between Molina Healthcare of Ohio and the OhioRISE Plan

+ Care Coordination Assignment

+ Provision of Member Information

+ Continuation of Services for Members

+ Documentation of Transition of Services

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: $77,969 - $128,519 / ANNUAL

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

**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 make medical determinations as necessary, and applies clinical knowledge to assess the medical necessity, level of services, and/or appropriateness of care in cases. 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 Affairs, in order to achieve and maintain appropriate anti-fraud oversight.

**Job Duties**

• Perform objective desk and onsite medical record audits to verify if services were supported by documentation, to determine if services were appropriately administered, and/or to validate coding/billing accuracy.

• Conduct interviews of providers and/or health plan members in order to determine whether fraud, waste, or abuse may have occurred.

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

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

• Incorporate leadership and communication skills to work with physicians and other health professionals when investigating cases.

• Generate and provide accurate and timely written reports for internal and/external use detailing audit findings.

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

• Identify opportunities for improvement through the audit process and provide recommendations for system enhancement in order to augment investigative outcomes and performance.

**JOB QUALIFICATIONS**

**REQUIRED EDUCATION** :

Graduate from an Accredited School of Nursing.

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

+ Five years clinical nursing experience with broad clinical knowledge.

+ Five years experience conducting medical review and coding/billing audits involving professional and facility based services.

+ Knowledge and understanding of medical terminology along with demonstrated knowledge of CPT, ICD-9, HCPCS and DRG requirements.

+ Two years of managed care experience.

**REQUIRED LICENSE, CERTIFICATION, ASSOCIATION** :

Active, unrestricted State Registered Nursing (RN) license in good standing.

**PREFERRED EDUCATION** :

Bachelor’s Degree in Nursing

**PREFERRED EXPERIENCE** :

+ Experience in government programs (i.e., Medicare, Medicaid, & SCHIP).

+ Experience in long-term care.

**STATE SPECIFIC REQUIREMENTS** :

OHIO:

+ Transitions of Care for New Members

+ Molina Healthcare of Ohio follows the transition of care requirements outlined below and in Appendix D of the contract for new members transitioning to the MCO from fee-for-service (FFS) or another MCO. The Transition of Care Coach will coordinate all services with new members to ensure a seamless transition and ensure continuity of care.

+ Provision of Member Information

+ Pre-Enrollment Planning

+ The Molina Transition of Care Coach coordinates with and utilizes data provided by ODM, another MCO, the OhioRISE Plan (when applicable) and or collected by Molina (e.g. through assessments, new member outreach in advance of the member’s enrollment effective date) to identify existing sources of care and to ensure each new member is able to continue to receive existing services without disruption.

+ For OhioRISE Plan enrolled members, Molina will reach out to the OhioRISE Plan and primary care coordination staff to engage the OhioRISE Plan in pre-enrollment planning

+ Continuation of Services for Members

+ Documentation of Transition of Services

+ Transitions of Care Between Health Care Settings

+ Transitions of Care Between Molina Healthcare of Ohio and the OhioRISE Plan

+ Care Coordination Assignment

+ Provision of Member Information

+ Continuation of Services for Members

+ Documentation of Transition of Services

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: $77,969 - $128,519 / ANNUAL

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

**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.

**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 make medical determinations as necessary, and applies clinical knowledge to assess the medical necessity, level of services, and/or appropriateness of care in cases. 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 Affairs, in order to achieve and maintain appropriate anti-fraud oversight.

**Job Duties**

• Perform objective desk and onsite medical record audits to verify if services were supported by documentation, to determine if services were appropriately administered, and/or to validate coding/billing accuracy.

• Conduct interviews of providers and/or health plan members in order to determine whether fraud, waste, or abuse may have occurred.

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

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

• Incorporate leadership and communication skills to work with physicians and other health professionals when investigating cases.

• Generate and provide accurate and timely written reports for internal and/external use detailing audit findings.

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

• Identify opportunities for improvement through the audit process and provide recommendations for system enhancement in order to augment investigative outcomes and performance.

**JOB QUALIFICATIONS**

**REQUIRED EDUCATION** :

Graduate from an Accredited School of Nursing.

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

+ Five years clinical nursing experience with broad clinical knowledge.

+ Five years experience conducting medical review and coding/billing audits involving professional and facility based services.

+ Knowledge and understanding of medical terminology along with demonstrated knowledge of CPT, ICD-9, HCPCS and DRG requirements.

+ Two years of managed care experience.

**REQUIRED LICENSE, CERTIFICATION, ASSOCIATION** :

Active, unrestricted State Registered Nursing (RN) license in good standing.

**PREFERRED EDUCATION** :

Bachelor’s Degree in Nursing

**PREFERRED EXPERIENCE** :

+ Experience in government programs (i.e., Medicare, Medicaid, & SCHIP).

+ Experience in long-term care.

**STATE SPECIFIC REQUIREMENTS** :

OHIO:

+ Transitions of Care for New Members

+ Molina Healthcare of Ohio follows the transition of care requirements outlined below and in Appendix D of the contract for new members transitioning to the MCO from fee-for-service (FFS) or another MCO. The Transition of Care Coach will coordinate all services with new members to ensure a seamless transition and ensure continuity of care.

+ Provision of Member Information

+ Pre-Enrollment Planning

+ The Molina Transition of Care Coach coordinates with and utilizes data provided by ODM, another MCO, the OhioRISE Plan (when applicable) and or collected by Molina (e.g. through assessments, new member outreach in advance of the member’s enrollment effective date) to identify existing sources of care and to ensure each new member is able to continue to receive existing services without disruption.

+ For OhioRISE Plan enrolled members, Molina will reach out to the OhioRISE Plan and primary care coordination staff to engage the OhioRISE Plan in pre-enrollment planning

+ Continuation of Services for Members

+ Documentation of Transition of Services

+ Transitions of Care Between Health Care Settings

+ Transitions of Care Between Molina Healthcare of Ohio and the OhioRISE Plan

+ Care Coordination Assignment

+ Provision of Member Information

+ Continuation of Services for Members

+ Documentation of Transition of Services

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: $77,969 - $128,519 / ANNUAL

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

**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.

**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.

**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 make medical determinations as necessary, and applies clinical knowledge to assess the medical necessity, level of services, and/or appropriateness of care in cases. 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 Affairs, in order to achieve and maintain appropriate anti-fraud oversight.

**Job Duties**

• Perform objective desk and onsite medical record audits to verify if services were supported by documentation, to determine if services were appropriately administered, and/or to validate coding/billing accuracy.

• Conduct interviews of providers and/or health plan members in order to determine whether fraud, waste, or abuse may have occurred.

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

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

• Incorporate leadership and communication skills to work with physicians and other health professionals when investigating cases.

• Generate and provide accurate and timely written reports for internal and/external use detailing audit findings.

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

• Identify opportunities for improvement through the audit process and provide recommendations for system enhancement in order to augment investigative outcomes and performance.

**JOB QUALIFICATIONS**

**REQUIRED EDUCATION** :

Graduate from an Accredited School of Nursing.

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

+ Five years clinical nursing experience with broad clinical knowledge.

+ Five years experience conducting medical review and coding/billing audits involving professional and facility based services.

+ Knowledge and understanding of medical terminology along with demonstrated knowledge of CPT, ICD-9, HCPCS and DRG requirements.

+ Two years of managed care experience.

**REQUIRED LICENSE, CERTIFICATION, ASSOCIATION** :

Active, unrestricted State Registered Nursing (RN) license in good standing.

**PREFERRED EDUCATION** :

Bachelor’s Degree in Nursing

**PREFERRED EXPERIENCE** :

+ Experience in government programs (i.e., Medicare, Medicaid, & SCHIP).

+ Experience in long-term care.

**STATE SPECIFIC REQUIREMENTS** :

OHIO:

+ Transitions of Care for New Members

+ Molina Healthcare of Ohio follows the transition of care requirements outlined below and in Appendix D of the contract for new members transitioning to the MCO from fee-for-service (FFS) or another MCO. The Transition of Care Coach will coordinate all services with new members to ensure a seamless transition and ensure continuity of care.

+ Provision of Member Information

+ Pre-Enrollment Planning

+ The Molina Transition of Care Coach coordinates with and utilizes data provided by ODM, another MCO, the OhioRISE Plan (when applicable) and or collected by Molina (e.g. through assessments, new member outreach in advance of the member’s enrollment effective date) to identify existing sources of care and to ensure each new member is able to continue to receive existing services without disruption.

+ For OhioRISE Plan enrolled members, Molina will reach out to the OhioRISE Plan and primary care coordination staff to engage the OhioRISE Plan in pre-enrollment planning

+ Continuation of Services for Members

+ Documentation of Transition of Services

+ Transitions of Care Between Health Care Settings

+ Transitions of Care Between Molina Healthcare of Ohio and the OhioRISE Plan

+ Care Coordination Assignment

+ Provision of Member Information

+ Continuation of Services for Members

+ Documentation of Transition of Services

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: $77,969 - $128,519 / ANNUAL

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

**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.