Manager, Special Investigations Unit

Position:
Manager, Special Investigations Unit

Talent Area:
Professional - Non-Clinical

Full/Part Time:
Full time

Location:

Houston, TX, US

Department: TCHP Program Integrity

Shift: 8a-5p Monday-Friday

In this role 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. Oversight of case management, case investigation, over payment recoveries, reporting of investigations to regulatory agencies; response to government requests for information related to FWA; facilitation of compliance with state and federal FWA requirements;

development and maintenance of employee education; and identification of new recovery opportunities, goals and sound practices.

• 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.
• Implement processes and procedures to prevent, detect, investigate and report FWA to appropriate regulatory agencies.
• Provide inter-departmental input regarding controls for preventing and monitoring FWA issues.
• Proactively identify trends and aberrant activity to generate leads for FWA investigations.
• Perform special assignments related to FWA as assigned by the Director of Controls and Compliance.
• Accountable for managing the day-to-day activities of the SIU Department, reporting directly to the Director of Controls and Compliance.
• Develop and maintain outcome-focused SIU Policies & Procedures which are consistent with all applicable contractual and regulatory requirements.
• Support 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.
• Conduct comprehensive analysis of claim utilization data to prevent payment of fraudulent claims.
• Assist with data mining activities using available tools and applications.
• Develop and implement plans for operations in cases of prospective and retrospective fraud, waste and abuse and over payment recovery.
• Provide periodic internal and external training to all staff and contractors on fraud, waste, and abuse.
• Develop and maintain strong working relationships with company management, associates and State regulators.

• Required High School Diploma/GED or
• Bachelor’s Degree preferred
• One of the following Certification:
• EDUHRUSE
• CPA:
  Certified Public Accountant
• CFA:
  Certified Fraud Examiner
• AHFI: NHCCA National Health Care Anti-Fraud Association
• Required 8 years' experience in fraud, waste & abuse (FWA) investigations or special investigations unit (SIU), including 1 year of experience working with Medicaid

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 15,000+ 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.