Career | Texas Children’s People

Position: Senior Special Investigator Unit - The Health Plan

Talent Area: Professional - Non-Clinical

Full/Part Time: Full time

Location: Houston, TX, US

Department: Controls & Compliance

Shift: 8a-5p

Job ID: 412652

We are searching for a Senior Investigator 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 the 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.

Skills & Requirements

H.S. Diploma or GED
6 years’ experience in claims examination, adjusting, fraud detection, or investigations preferably in a healthcare environment.
Preferred certification as an Accredited Health Care Fraud Investigator (AHFI) by the National Healthcare Anti-Fraud Association (NHCAA)

Job Duties & 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

Please note: this is a hybrid position. Onsite/In-office work will be required each week

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.