Long Beach, California, United States · On-site
Job Description Job Summary Provides senior level support for special investigation unit (SIU) activities. Responsible for supporting for the prevention, detection, investigation, reporting, and when appropriate, recover…
Skills: Fraud Investigation, Data Analysis, Healthcare Compliance, Medical Coding, Interviewing
Long Beach, California, United States · On-site
JOB DESCRIPTION Job Summary Provides subject matter expertise and leadership for health plan provider relations activities. Supports network development, network adequacy and provider training and education. Serves as pr…
Skills: Provider Relations, Network Management, Healthcare Delivery System, Medicaid, Medicare
Long Beach, California, United States · Remote OK
Job Description Job Summary Directs and leads reporting, analytics, and data‑driven insights that support strategic, operational, financial, clinical, and regulatory decision‑making across Molina. This role is accountabl…
Skills: Data Strategy, Healthcare Analytics, SQL, Relational Databases, Executive Reporting
Long Beach, California, United States · On-site
JOB DESCRIPTION Job Summary The schedule for this position is M-F 11:30am-8pm. Leads and supervises team responsible for provision of support center customer service excellence to meet the needs of Molina members and pro…
Skills: Customer Service, Call Center Management, Leadership, Medicaid, Medicare
Long Beach, California, United States · Hybrid
JOB DESCRIPTION This RN will act as a Care Coordinator (Long Term Care Services) supporting our Medicaid and Medicare dual members. The Care Coordinator will support them to ensure their long-term services and support ne…
Skills: Care Coordination, Case Management, Member Assessment, Care Planning, Motivational Interviewing
Long Beach, California, United States · On-site
$24/hr–$46/hr
JOB DESCRIPTION Family Care with My Choice Wisconsin Job Summary Provides support for care management/care coordination long-term services and supports (LTSS)-specific activities. Collaborates with multidisciplinary team…
Skills: Care Management, Care Coordination, Member Assessment, Care Planning, Waiver Enrollment
Long Beach, California, United States · On-site
JOB DESCRIPTION Job Summary Provides support for care management/care coordination long-term services and supports (LTSS)-specific activities. Collaborates with multidisciplinary team coordinating integrated delivery of …
Skills: Care Management, Care Coordination, Member Assessment, Care Planning, Waiver Enrollment
Long Beach, California, United States · Remote OK
$50k–$97k/yr
JOB DESCRIPTION Job Summary Responsible for accurate and timely intake and interpretation of regulatory and/or functional requirements related to but not limited to coverage, reimbursement, and processing functions to su…
Skills: Regulatory Analysis, Requirement Documentation, Problem Management, Stakeholder Coordination, Root Cause Analysis
Long Beach, California, United States · On-site
$15/hr–$24/hr
JOB DESCRIPTION Job Summary Provides level I support center customer service excellence to meet the needs of Molina members and providers. Resolves issues and addresses needs fairly and effectively, while demonstrating M…
Skills: Customer Service, Call Center Operations, Data Processing, Time Management, HIPAA Compliance
Long Beach, California, United States · On-site
$24/hr–$46/hr
JOB DESCRIPTION Opportunity for TX RN to join Molina as a Care Manager working with our Medicaid members in Houston. The service delivery area is in neighborhoods north of East Crosstimbers Street to East Little York/Hom…
Skills: Care Management, LTSS, Member Assessments, Care Planning, Waiver Enrollment
Long Beach, California, United States · Hybrid
JOB DESCRIPTION Job Summary Do you want a career where you build lasting relationships with the people you partner with? Do you want to make a difference in the lives of people with long-term health care needs? Then TMG …
Skills: Care Coordination, Case Management, Budget Management, Community Resource Research, HIPAA Compliance
Long Beach, California, United States · Hybrid
Home Health Care, Hospice Care, Palliative Care, Long Term Care, Rehab No weekends, No afterhours support, No holidays Job Description Job Summary Are you seeking a unique nursing position that gives you a great work/lif…
Skills: Personal Care Assessment, Case Management, Patient Education, Care Planning, Clinical Documentation
Long Beach, California, United States · Hybrid
Home Health Care, Hospice Care, Palliative Care, Long Term Care, Rehab No weekends, No afterhours support, No holidays Job Description Job Summary Are you seeking a unique nursing position that gives you a great work/lif…
Skills: Personal Care Assessment, Case Management, Patient Education, Care Planning, Clinical Documentation
Long Beach, California, United States · On-site
JOB DESCRIPTION Job Summary Provides lead level support for team supporting integrated behavioral health/chemical dependency services and long-term care for members with high-need potential. In collaboration with multidi…
Skills: Behavioral Health Expertise, Case Management, Clinical Screening, Regulatory Compliance, Interdisciplinary Collaboration
Long Beach, California, United States · On-site
$15/hr–$31/hr
Job Description: Responds to incoming calls from providers regarding claims inquiries - provides excellent customer service, support and issue resolution; documents all calls and interactions. Provides support for provid…
Skills: Claims Adjudication, Customer Service, Data Analysis, Provider Relations, Research
Long Beach, California, United States · Remote OK
$60k–$130k/yr
Job Description Job Summary Provides senior level analysis for complex data to generate insights that support strategic and operational decision-making. This role designs and delivers reporting, analytics, and data solut…
Skills: SQL, Data Analysis, Microsoft Excel, SSRS, Healthcare Analytics
Long Beach, California, United States · Hybrid
$24/hr–$46/hr
***Remote with travel through Chippewa & Eau Claire Counties, WI for member visits*** JOB DESCRIPTION Job Summary Provides support for care management/care coordination long-term services and supports (LTSS)-specific act…
Skills: Care Management, Care Coordination, Member Assessment, Waiver Enrollment, Care Planning
Long Beach, California, United States · On-site
$66k–$130k/yr
JOB DESCRIPTION Job Summary Leads and supervises multidisciplinary team of healthcare services professionals in some or all of the following functions: care management, utilization management, behavioral health, care tra…
Skills: Care Management, Utilization Management, Behavioral Health, Care Transitions, LTSS
Long Beach, California, United States · On-site
$14/hr–$29/hr
Job Description Job Summary Responsible for continuous quality improvements regarding member engagement and member retention. Represents Member issues in areas involving member impact and engagement including: Appeals an…
Skills: Member Engagement, Member Retention, Consumer Advocacy, Case Management, Conflict Resolution
Long Beach, California, United States · Remote Solely
Molina Healthcare is hiring for a Pharmacy Technician who is State Licensed/Certified and/or PTCB certified. This role is 100% remote, and the hours will be Mon-Fri 10am to 630pm Pacific Standard Time. This role will be …
Skills: Prior Authorization, Pharmacy Claims, Managed Care, Medical Necessity Review, HIPAA Compliance
Long Beach, California, United States • On-site
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Provides senior-level support for the Special Investigative Unit to prevent, detect, and recover funds related to healthcare fraud, waste, and abuse. Conducts complex investigations, analyzes claims data, and maintains relationships with external law enforcement and regulatory agencies.
Requires at least 3 years of healthcare investigative experience and a valid driver's license. Candidates must possess strong analytical skills and knowledge of Medicaid, Medicare, and healthcare billing codes.
Job Summary
Provides senior level support for special investigation unit (SIU) activities. Responsible for supporting for the prevention, detection, investigation, reporting, and when appropriate, recovery of money related to health care fraud, waste, and abuse (FWA). Responsible for reviewing and analyzing information to draw conclusions on allegations of FWA and/or may determine appropriateness of care, and recognizing and adhering to national and local coding and billing guidelines in order to maintain coding accuracy and excellence.
• At least 3 years investigative experience in the health care industry, or equivalent combination of relevant education and experience.
• Valid and unrestricted driver’s license.
• Proven investigatory skills including ability to organize, analyze, and effectively determine risk with corresponding solutions, and remain objective and separate facts from opinions.
• Knowledge of investigative and law enforcement procedures with emphasis on fraud investigations.
• Knowledge of managed care and Medicaid, Medicare, and Marketplace programs.
• Understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems.
• Understanding of datamining and use of data analytics to detect FWA.
• Ability to research and interpret regulatory requirements.
• Effective interpersonal skills and customer service focus ability to interact with individuals at all levels.
• Strong presentation skills with ability to create and deliver training, informational and other types of programs.
• Strong logical, analytical, critical-thinking and problem-solving skills.
• Strong sense of initiative, excellent follow-through, and 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, and 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.
• Effective verbal and written communication skills.
• Microsoft Office suite (Word, Excel, PowerPoint, Outlook), SharePoint, Intranet/Internet, and applicable software program(s) proficiency, and ability and experience incorporating/merging documents from various applications.
Preferred Qualifications
• Accredited Health Care Fraud Examiner (AHFI) and/or 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.
Molina Healthcare is a FORTUNE 500 company that is focused exclusively on government-sponsored health care programs for families and individuals who qualify for government sponsored health care. Molina Healthcare contracts with state governments and serves as a health plan providing a wide range of quality health care services to families and individuals. Molina Healthcare offers health plans in Arizona, California, Florida, Idaho, Illinois, Kentucky, Massachusetts, Michigan, Mississippi, Nevada, New Mexico, New York, Ohio, South Carolina, Texas, Utah, Virginia, Washington and Wisconsin. Molina also offers a Medicare product and has been selected in several states to participate in duals demonstration projects to manage the care for those eligible for both Medicaid and Medicare.
Offices: 200 Oceangate, Long Beach, California 90802, US
Molina Healthcare is a FORTUNE 500 company that is focused exclusively on government-sponsored health care programs for families and individuals who qualify for government sponsored health care. Molina Healthcare contracts with state governments and serves as a health plan providing a wide range of quality health care services to families and individuals. Molina Healthcare offers health plans in Arizona, California, Florida, Idaho, Illinois, Kentucky, Massachusetts, Michigan, Mississippi, Nevada, New Mexico, New York, Ohio, South Carolina, Texas, Utah, Virginia, Washington and Wisconsin. Molina also offers a Medicare product and has been selected in several states to participate in duals demonstration projects to manage the care for those eligible for both Medicaid and Medicare.
Offices: 200 Oceangate, Long Beach, California 90802, US
