Special Investigations Unit Senior Investigator

 
Position: Special Investigations Unit Senior Investigator

Job ID: 164482

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

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.  At Texas Children’s Hospital, diversity, equity, and inclusion are at the core of our values and mission for the women and children 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 a Special Investigations Unit Senior Investigator -- someone who works well in a fast-paced setting. In this position, you will assist the Director of Controls and Compliance and Special Investigative Unit Manager in conducting investigations into suspected incidents of Fraud, Waste, and Abuse (FWA).  This includes data mining for potential intakes, performing preliminary analysis on provider cases, and working on projects focused on preventing, detecting, and correcting fraud, waste, and abuse.

 

 Think you’ve got what it takes?



Responsibilities :

  • Completes detailed and extensive investigations in adherence to the organization’s procedures and best practices. Gathers evidence and makes determinations regarding potential recoveries
  • Independently develops and executes appropriate investigation strategies for assigned cases. Leads in-depth interviews of participants, witnesses, or affected parties
  • Researches and prepares cases for clinical and legal reviews and conducts reviews of flagged claims and suspected FWA, identifying opportunities for improving payment accuracy and preventing FWA
  • Prepares accurate, timely, unbiased, and detailed written reports and case summaries in compliance with corporate standard operating procedures and guidelines documenting investigative results
  • Prepares referrals for preliminary investigations, including but not limited to: Requesting medical records, creating forms, reports and updating logs
  • Maintains case management log with investigative notes, reports, and summaries
  • Partners with the federal and state agencies on data requests, projects, investigations, and meetings
  • Communicates investigation outcomes to implement provider and other compliance


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

  • High School Diploma
  • 6 years’ experience in claims examination, claims audit/UR, claims adjusting, fraud detection or Special Investigations Unit experience required
  • Certification as an Accredited Health Care Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE) preferred


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