Texas Children's Hospital
Overview
We’re seeking an Investigator for the Special Investigative Unit (SIU) who works well in a fast-paced setting. In this position, you will assist the Director of Controls and Compliance and the 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.
Responsibilities
Conduct Fraud, Waste and Abuse (FWA) and related compliance investigations.
Complete detailed investigations in adherence with the organization’s procedures and best practices. Gather evidence and determine potential recoveries.
Research and prepare cases for clinical and legal reviews.
Review flagged claims and suspected FWA, identifying opportunities to improve payment accuracy and prevent FWA.
Analyze compliance and FWA cases for root causes and trends, track data to translate findings, and develop processes for improvement or investigation.
Prepare accurate, timely, unbiased, and detailed written reports and case summaries in compliance with corporate SOPs and guidelines documenting investigative results.
Prepare referrals for preliminary investigations, including requesting medical records, creating forms, reports, and updating logs.
Facilitate the recovery of inappropriate payments from FWA matters.
Draft recoupment letters for FWA findings.
Support other investigators in SIU operations.
Maintain case management log with investigative notes, reports, and summaries.
Proactively collaborate with line-of-business personnel to generate referrals.
Partner with federal and state agencies on data requests and investigations.
Maintain the organization’s confidential information in accordance with corporate policies and state and federal laws regarding confidentiality.
Skills & Requirements
Required High School Diploma or GED with a preferred bachelor's degree.
Required 2 years of claims examination, claims adjusting, fraud detection, or investigations/SIU experience, preferably in a healthcare environment.
About Us 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.
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.
Job Details
Seniority level: Entry level
Employment type: Full-time
Job function: Other, Information Technology, and Management
Industries: Hospitals and Health Care
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Responsibilities
Conduct Fraud, Waste and Abuse (FWA) and related compliance investigations.
Complete detailed investigations in adherence with the organization’s procedures and best practices. Gather evidence and determine potential recoveries.
Research and prepare cases for clinical and legal reviews.
Review flagged claims and suspected FWA, identifying opportunities to improve payment accuracy and prevent FWA.
Analyze compliance and FWA cases for root causes and trends, track data to translate findings, and develop processes for improvement or investigation.
Prepare accurate, timely, unbiased, and detailed written reports and case summaries in compliance with corporate SOPs and guidelines documenting investigative results.
Prepare referrals for preliminary investigations, including requesting medical records, creating forms, reports, and updating logs.
Facilitate the recovery of inappropriate payments from FWA matters.
Draft recoupment letters for FWA findings.
Support other investigators in SIU operations.
Maintain case management log with investigative notes, reports, and summaries.
Proactively collaborate with line-of-business personnel to generate referrals.
Partner with federal and state agencies on data requests and investigations.
Maintain the organization’s confidential information in accordance with corporate policies and state and federal laws regarding confidentiality.
Skills & Requirements
Required High School Diploma or GED with a preferred bachelor's degree.
Required 2 years of claims examination, claims adjusting, fraud detection, or investigations/SIU experience, preferably in a healthcare environment.
About Us 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.
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.
Job Details
Seniority level: Entry level
Employment type: Full-time
Job function: Other, Information Technology, and Management
Industries: Hospitals and Health Care
#J-18808-Ljbffr