Senior Investigator in the Special Investigations Unit - The Health Plan

 
Position: Senior Investigator in the Special Investigations Unit - The Health Plan

Job ID: 157576

Location: US-TX-Bellaire

Department: Controls & Compliance

Talent Area: Professional - Non-Clinical

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a - 5p

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 Senior Investigator in the Special Investigations Unit (SIU) -- someone who works well in a fast-paced setting. In this position, you will assist the SIU Manager in conducting investigations into suspected incidents of Fraud, Waste, and Abuse (FWA). This includes identifying FWA through data analysis/mining, performing preliminary and full investigations on Medicaid providers suspected of FWA, coordinating SIU activities and initiatives with stakeholders, and working on initiatives focused on preventing and detecting FWA.

Think you’ve got what it takes?



Responsibilities :

  • Conduct Fraud, Waste and Abuse (FWA) and related compliance investigations
  • Maintain case management log with investigative notes, reports and summaries
  • Proactively collaborate with line of business personnel to generate referrals
  • Partner with the federal and state agencies on data requests, projects, investigations and meetings
  • Communicate investigation outcomes to line of business personnel and partners to implement provider and other compliance/ SIU related edits when appropriate
  • Maintain organization’s confidential information in accordance with corporate policies, as well as state and federal laws, rules and regulations regarding confidentiality
  • Complete detailed and extensive investigations in adherence with organization’s procedures and best practices
  • Gather evidence and makes determinations regarding potential recoveries
  • Responsible for conducting and/or coordinating medical compliance audits and utilization reviews (UR)
  • Independently develop and execute appropriate investigation strategies for assigned cases
  • Lead in-depth interviews of participants, witnesses or affected parties


Qualifications:

  • Bachelor’s degree required
  • 4 years’ experience in claims examination, claims audit/UR, claims adjusting, fraud detection or SIU experience required
  • Certification as an Accredited Health Care Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE) preferred


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