About Texas Children's HospitalTexas 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.
We are searching for a Manager of the Special Investigations Unit -- 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. Oversees case management, case investigation, overpayment recoveries, and reporting of investigations to regulatory agencies; responds 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.
Think you’ve got what it takes?
· 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
· 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
· 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
· Implements processes and procedures to: prevent, detect, investigate and report FWA to appropriate regulatory agencies
· Provides inter-departmental input regarding controls for preventing and monitoring FWA issues
· Proactively identifies trends and aberrant activity to generate leads for FWA investigations
· Performs special assignments related to FWA as assigned by the Director of Controls and Compliance.
· 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 which are consistent with all applicable contractual and regulatory requirements
· Supports 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
· Conducts comprehensive analysis of claim utilization data to prevent payment of fraudulent claims
· Assist with data mining activities using available tools and applications
· Develops and implements plans for operations in cases of prospective and retrospective fraud, waste and abuse and overpayment recovery
· Provides periodic internal and external training to all staff and contractors on fraud, waste, and abuse
· Develops and maintains strong working relationships with company management, associates and State regulators
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
· Bachelor's Degree
· 5 years’ experience in fraud, waste & abuse (FWA) investigations or special investigations unit (SIU), including 1 year of experience working with Medicaid