Lead, Special Investigation Unit (Remote)

Job Description

JOB DESCRIPTION

Job Summary

Under direct supervision of the Manager, SIU, the Team Lead is responsible to lead a small team of investigators and provide oversight on daily investigative activities as a back-up to the SIU Manager. This position will be accountable for tracking on investigations conducted by his / her team and will provide oversight and guidance throughout the life of an investigation as well as QA reviews and approvals. In addition to leading a team of investigators and analysts, the Team Lead will ensure the Manager is aware of any major case developments, and ensure cases are being investigated according to the SIU's standards. Position must have thorough knowledge of Medicaid / Medicare / Marketplace health coverage audit policies and be able to apply them in ensuring program compliance via payment integrity programs. The position must have the ability to determine correct coding, documentation, potential fraud, abuse, and over utilization by providers and recipients. The position will review claims data, medical records, and billing data from all types of healthcare providers that bill Medicaid / Medicare / Marketplace.

KNOWLEDGE / SKILLS / ABILITIES

• Ensure investigators are managing their cases effectively and in accordance with SIU policies, processes, quality standards, and procedures.
• Ensure that investigators are managing their respective State Reporting requirements and assignments effectively and timely.
• Manage the flow of day-to-day investigations.
• Perform assessment that QA measures were complete and signed-off
• Provide guidance to investigators as needed on investigative techniques, tools, or strategy.
• Effectively investigate and manage complex and non-complex fraud allegations.
• Develop and maintain relationships with key business units within specific product line and geographic region.
• Provides direction, instructions, and guidance to Investigative team, particularly in the absence of the SIU Manager.
• Provide training to team members as needed.
• Communicate clear instructions to team members, listen to team members' feedback.
• Monitor team members' participation to ensure the training provided is effective, and if any additional training is needed.
• Create, edit, and update assigned reports to apprise the company on the team's progress.
• Distribute reports to the appropriate personnel.

JOB QUALIFICATIONS

Required Education

High School / GED.

Required Experience

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.