Manager, Special Investigations Unit, Controls & Compliance

 
Position: Manager, Special Investigations Unit, Controls & Compliance

Job ID: 153301

Location: US-TX-Bellaire

Department: Controls & Compliance

Talent Area: Professional - Non-Clinical

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8-5

About Texas Children's Hospital

Texas Children’s Hospital Since 1954, Texas Children’s has been leading the charge in patient care, education and research to accelerate health care for children and women around the world. When you love what you do, it truly shows in the smiles of our patient families, employees and our numerous accolades such as being consistently ranked as the best children’s hospital in Texas, and among the top in the nation by U.S.News & World Report as well as recognition from Houston Business Journal as one of this city’s Best Places to Work for ten consecutive years.   Texas Children’s comprehensive health care network includes our primary hospital in the Texas Medical Center with expertise in over 40 pediatric subspecialties; the Jan and Dan Duncan Neurological Research Institute (NRI); the Feigin Center for pediatric research; Texas Children’s Pavilion for Women, a comprehensive obstetrics/gynecology facility focusing on high-risk births; Texas Children’s Hospital West Campus, a community hospital in suburban West Houston; and Texas Children’s Hospital The Woodlands, the first hospital devoted to children’s care for communities north of Houston. We have also created the nation’s first HMO for children, established the largest pediatric primary care network in the country and a global health program that is channeling care to children and women all over the world. Texas Children’s Hospital is also academically affiliated with Baylor College of Medicine, one of the largest, most diverse and successful pediatric programs in the nation.   To join our community of 14,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org.   Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

Summary:

We are searching for a Special Investigations Unit Manager — someone who works well in a fast-paced setting. In this position, you will be responsible for overseeing the Special Investigations Unit (SIU) and Fraud, Waste & Abuse (FWA) Program in is compliance with contractual and regulatory requirements. This role will oversee case management, case investigation, overpayment recoveries, and reporting of investigations to regulatory agencies. Lastly, this position will respond to government requests for information related to FWA, facilitate compliance with state and federal FWA requirements, develop and maintain employee education, and identify new recovery opportunities, goals, and sound practices.

Think you’ve got what it takes?



Responsibilities :

Direct and oversee investigations related to Fraud, Waste & Abuse and coordinate with subcontractors on overseeing investigations

·        Provide internal and external case updates on the progression of investigations in coordination with SIU team members and other departments, including recommendations on further action and/or resolution, as needed

·        Develop and maintain outcome-focused SIU policies & procedures which are consistent with all applicable contractual and regulatory requirements

·        Implement processes and procedures to prevent, detect, investigate, and report FWA to appropriate regulatory agencies

·        Support internal and external SIU reviews as appropriate, including accurate tracking of case information and timely reporting as needed for internal and external audits, contractual requirements, and regulatory oversight

·        Conduct a comprehensive analysis of claim utilization data to prevent payment of fraudulent claims



Qualifications:

  • A minimum of 5 years’ experience in fraud, waste & abuse (FWA) investigations or special investigations unit (SIU), including 1 year of experience working with Medicaid
  • Bachelor’s Degree in a related field or discipline. 
  • Accredited Healthcare Fraud Investigator (AHFI) Certification
  • Preferred qualifications: Certified Professional Coder (CPC), Certified Fraud Examiner (CFE)


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