Manager, Special Investigation Unit
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 the following programs:
• Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
• Children’s Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
• Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.
Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.
The Manager, SIU manages a team in the Special Investigations Unit to detect, investigate, remediate and refer to state regulatory agencies and/or law enforcement as appropriate, incidents of fraud, waste and abuse (FWA) arising in connection with medical, behavioral, dental, transportation, pharmacy, and other healthcare services. This position will be accountable for all investigations conducted by his/her team and will provide oversight and approval of the investigations from the planning phase through the disposition. This position is dedicated to Community's lines of business (CHIP, Medicaid, Commercial), and oversees all aspects of FWA within those segments.
The manager must have the ability to determine correct coding, review claims, review medical records, and billing data from all types of healthcare providers for aberrant billing patterns. Additional duties are:
- managing case assignments, case development, case review, overpayment recoveries, managing RFIs, state agency and/or law enforcement referrals, training of staff, and coordination with other departments to mitigate and remedy FWA.
- developing, implementing and managing strategic FWA activities by maintaining state and federal requirements and monitoring trends and schemes.
- Bachelor's degree required.
- Certification (Accredited Healthcare Fraud Investigator and/or Certified Fraud Examiner, etc.) required.
- Graduate degree and certifications (i.e., MS Psychology, MBA, J.D., Masters in Criminal Justice, Masters in Forensic Accounting, etc.) preferred.
- Five years conducting comprehensive healthcare insurance investigations, and interacting with state, federal, and local law enforcement agencies.
- Three years Healthcare SIU managerial/supervisory experience.
- Investigative experience (State or local law enforcement, FBI, CIA, DEA, Secret Service, OIG, General Accounting Office, MFCU, government agencies, corporate investigations, insurance company, law firm, accounting firm, auditing or similar professional experience).
- Experience working with Medicare and Medicaid regulations, understanding of healthcare industry, claims processing, investigative process, and auditing a plus.
- Excellent leadership, team building, and strategic thinking skills.
- Proven project planning and management skills
- Ability to analyze and interpret financial data in order to coordinate the preparation of financial records.
- Strong problem solving skills.
- Ability to prepare and present training sessions.
- Excellent written and verbal communication skills.
- Successful track record in facilitating and managing projects and teams
- Strong organizational, interpersonal, and communication skills
Benefits and EEOC
Community employees’ benefits are provided by Harris Health. These benefits are designed to provide you with flexibility and choices in meeting your specific needs.
Community is an Equal Opportunity Employer.