Mgr Special Investigations Unt

 
Position: Mgr Special Investigations Unt

Job ID: 153990

Location: US-TX-Bellaire

Department: Controls & Compliance

Talent Area: Professional - Non-Clinical

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8 AM to 5 PM

About Texas Children's Hospital

Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.   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 the oversight of the Special Investigations Unit (SIU) and Fraud, Waste & Abuse (FWA) Program in compliance with contractual and regulatory requirements. You will oversee case management, case investigation, overpayment recoveries and reports of investigations to regulatory agencies. You will also 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 :

  • Manages a large fraud investigation caseload and investigates allegations relating to potential health care fraud perpetrated by Medicaid and commercial providers, vendors and enrollees
  • Provides internal and external case updates on progression of investigations in coordination with SIU team members and other departments, including recommendations on further action and/or resolution as needed
  • Implements processes and procedures to prevent, detect, investigate and report FWA to appropriate regulatory agencies
  • Proactively identifies trends and aberrant activity to generate leads for FWA investigations
  • Directs and oversees the Special Investigation Unit (SIU)
  • Develops and maintains outcome-focused SIU Policies & Procedures which are consistent with all applicable contractual and regulatory requirements
  • Conducts comprehensive analysis of claim utilization data to prevent payment of fraudulent claims
  • Assist with data mining activities using available tools and applications
  • Provides periodic internal and external training to all staff and contractors of fraud, waste, and abuse


Qualifications:

  • Bachelor’s degree required
  • 5 years’ experience in fraud, waste & abuse (FWA) investigations, or special investigations unit (SIU) including 1 year of experience working with Medicaid required
  • CFE and AHFI certification strongly preferred
  • Knowledge of medical terminology and/or experience with CPT codes and ICD-9, ICD-10 coding
  • Knowledge of suspected FWA trends and matters of interest to law enforcement and regulators


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