Job description

JOB DESCRIPTION

Job Summary

Establish a specifically designed compliance program that effectively prevents and/or detects violation of applicable laws and regulations, which will protect the Business from liability of fraudulent or abusive practices. Ensures that the Business understands and complies with applicable laws and regulations pertaining to the Health Care environment. Ensures the Business' accountability for compliance by overseeing, follow-up and resolution of investigations.

KNOWLEDGE/SKILLS/ABILITIES

Provides oversight and review of the SIU referral intake and investigation process while giving guidance and direction to team on case investigation steps and actions.

Works with leadership to maintain and revise policies and procedures, fraud, waste, and abuse plans, annual audit work plans, including department guidance memos, and educational materials.

Identifies opportunities for improvement through the audit process and provide recommendations for system enhancement to augment investigative outcomes and performance.

Accurately tracks, reports, and follows up on overpayments and recoveries

Leads business requirement process and reporting to ensure proper and timely notification of case activity to the appropriate regulatory and/or law enforcement agency.

JOB QUALIFICATIONS

Required Education

Bachelor's Degree or equivalent combination of education and experience

Required Experience

5-7 years

Required License, Certification, Association

Active and unrestricted Accredited Health Care Fraud Investigator (AHFI) designation or Certified Fraud Examiner (CFE)

Preferred Education

Master’s Degree preferred; will consider previous experience in health plan setting in government programs

Preferred Experience

7-9 years

Preferred License, Certification, Association

Health Care Anti-Fraud Associate (HCAFA) designation

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.

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