SIU Investigator

Overview

Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with programs including Medicaid STAR, Children’s Health, Health Insurance Marketplace Plans, and CHC HMO D-SNP. Community is accredited by URAC for its health plan operations and offers care management programs for asthma, diabetes, and high-risk pregnancy.

An affiliate of the Harris Health System, Community is financially self-sufficient and receives no financial support from Harris Health or Harris County taxpayers.

Improving Members’ experiences is at the heart of every Community position, ensuring access to high-quality health care for those served.

The SIU Investigator is responsible for detecting, investigating, and preventing potential fraud, waste, and abuse (FWA) within claims and provider billing. This role conducts pre- and post-payment reviews, coordinates investigative efforts with internal and external stakeholders, and prepares detailed reports with findings and recommendations. The Investigator educates providers and staff on compliance and proper coding practices while ensuring adherence to federal and state regulations.

• Claims Investigation & Pre-Payment Review:
  Provide timely review and disposition of suspected case referrals, including determining alleged upcoding or unbundling of services. Review claim lines flagged by the SIU contractor and issue “do-not-pay” recommendations when appropriate. Gather and analyze claims data, medical records, contracts, and public records to determine if further action or formal investigation is warranted.
• Findings Development & Reporting:
  Develop and present findings and recommendations on the appropriateness of diagnosis and procedure codes submitted on provider service claims. Support discussions regarding potential over payments with providers and Community’s Fraud, Waste, and Abuse (FWA) Committee. Ensure the timely preparation and submission of required regulatory reports.
• Communication & Regulatory Liaison:
  Communicate review outcomes and the rationale for determinations clearly and professionally to providers, CHC staff, the FWA Committee, and regulatory agencies such as the Office of Inspector General (OIG) and the Texas Attorney General’s office.
• Education & Compliance Training:
  Educate providers, suppliers, pharmacies, and administrative staff on CMS, federal, and state statutory, regulatory, and contractual requirements. Deliver training on appropriate coding per AMA guidelines, acceptable practice standards, and procedures for preventing and reporting potential fraud and abuse. Present educational seminars on fraud and abuse awareness, detection, and reporting as required.
• Additional Duties:
  Actively contribute to the achievement of departmental goals identified in the Department’s annual business plan, including specific departmental process improvement plans. Other duties as assigned.