Assistant Director of Special Investigation Unit TCHP

 
Position: Assistant Director of Special Investigation Unit TCHP

Job ID: 164097

Location: US-TX-Houston

Department: Controls & Compliance

Talent Area: Professional - Non-Clinical

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a-5p

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.  At Texas Children’s Hospital, diversity, equity, and inclusion are at the core of our values and mission for all of our patients and families that we serve. We are committed to providing a diverse and inclusive work environment for all faculty, staff, and learners throughout our organization. We believe that each member of our one amazing team provides enrichment that allows us to create a lasting legacy for future employees of this great organization.     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 an Assistant Director of the Special Investigations Unit TCHP -- someone who works well in a fast-paced setting. In this position, you will oversee the Special Investigations Unit (SIU) and Fraud, Waste & Abuse (FWA) Program in compliance with contractual and regulatory requirements. Oversees case management, case investigation, overpayment recoveries, reporting of investigations to regulatory agencies; response to government requests for information related to FWA; facilitates compliance with state and federal FWA requirements; develops and maintains employee education; and identifies new recovery opportunities, goals and sound practices. Assists with the design of the overall programs, the yearly work plans approved by the board, and will have direct interaction with HHSC and executives.

 

Think you’ve got what it takes?



Responsibilities :

 

  • Directs and oversees investigations related to Fraud, Waste & Abuse. Coordinates with subcontractors on overseeing investigations of Fraud, Waste & Abuse (FWA). Manages a large fraud investigation caseload and investigates allegations relating to potential health care fraud perpetrated by Medicaid and commercial providers, vendors and enrollees
  • Directs and oversees the Special Investigation Unit (SIU). Accountable for managing the day-to-day activities of the SIU Department, reporting directly to the Director of Controls and Compliance. Develops and maintains outcome-focused SIU Policies & Procedures that are consistent with all applicable contractual and regulatory requirements
  • TCHP SIU department Annual Work Plan. Create annual work plans for the TCHP SIU department to be approved by the Audit & Compliance Board of Trustees. Ensures appropriate allocation of existing resources for adequate coverage and completion of the Annual Work.
  • Collaborates with other departments within TCHP and outside vendors to ensure the success of
  • the TCHP SIU program. Continually interfaces with members, vendors, pharmacies, providers and other third parties via telephone, e-mail, and on-site visits as needed to identify, further, and conclude ongoing investigations. Provides inter-departmental input regarding controls for preventing and monitoring FWA issues.


Qualifications:

 

Being fully vaccinated against COVID-19, including any booster dose(s) of the COVID-19 vaccine recommended by the Centers for Disease Control when eligible, is required for all employees at Texas Children’s unless approved for a medical or religious exemption

  • Required Bachelor's Degree. With a bachelor’s degree in Healthcare administration, accounting, auditing, business administration, information systems, research/data analysis, or other healthcare or business-related field of study and a Master's Degree
  • Certified Insurance Fraud Investigator (CIFI), Certified Fraud Examiner (CFA), and/or Certified Compliance & Ethic Professional (CCEP) preferred
  • Required 6 years’ experience in audit, compliance, fraud, waste & abuse (FWA) investigations, billing, and/or special investigations unit (SIU) experience, including at least six (6) months of formal management/supervisory experience. With a preferred 1 year experience working with Medicaid


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