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Professional - Non-Clinical
Special Investigative Unit - Investigator (Hybrid)
Houston, TX, US
We are searching for an Investigator for the Special Investigative Unit, 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 (SIU) Manager in investigating Fraud, Waste and Abuse for providers and members. This includes data mining for potential intakes, performing preliminary analysis on provider cases, and assisting with projects focused on detecting and preventing fraud, waste, and abuse.
Skills & Requirements
- 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 unless approved for a medical or religious exemption.
- Required H.S. Diploma or GED with a preferred bachelor's degree
- Required 2 years claims examination, claims adjusting, fraud detection, or investigations/special investigations unit (SIU) experience, preferably in a healthcare environment
Job Duties & Responsibilities
- Conducts Fraud, Waste and Abuse (FWA) and related compliance investigations.
- Completes detailed and extensive investigations in adherence with organization’s procedures and best practices.
- Gather evidence and determine potential recoveries.
- Researches and prepares cases for clinical and legal reviews.
- Conducts reviews of flagged claims and suspected FWA, identifying opportunities for improving payment accuracy and preventing FWA.
- Analyzes compliance and FWA cases for root cause, trends, and tracks data to translate findings, and develops processes for improvement or investigation.
- 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 requesting medical records, creating forms, reports and updating logs.
- Facilitates the recovery of inappropriate payments from FWA matters.
- Drafts recoupment letters for FWA findings.
- Supports other investigators in SIU operations.
- Maintains case management log with investigative notes, reports, and summaries.
- Proactively collaborates with line of business personnel to generate referrals.
- Partners with the federal and state agencies on data requests and investigations.
- Maintains organization’s confidential information in accordance with corporate policies, as well as state and federal laws, rules, and regulations regarding confidentiality.
About Texas Children’s
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.
