SIU Investigator
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.
• Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.
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.
JOB SUMMARY
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 also educates providers and staff on compliance and proper coding practices while ensuring adherence to federal and state regulations.
JOB SPECIFICATIONS
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 overpayments 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, Community Health Choice (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.
Actively contributes to the achievement of departmental goals, as identified in the Department's annual business plan, including specific departmental process improvement plans. Other duties as assigned.
QUALIFICATIONS:
' Education/Specialized Training/Licensure: Bachelor's degree required
' Must hold one of the following certifications: AHFI, or CFE (or equivalent). AHFI or CFE certification may be obtained within one year of employment if not already held required.
' CPC (or equivalent) certification preferred
' Work Experience (Years and Area): Minimum of 2 years' experience in healthcare investigations and/or medical coding, utilization management, or medical record auditing.
' Solid knowledge of Medicare, Medicaid, commercial insurance investigations and coding practices.
' Software Proficiencies: Proficiency in Microsoft Office (Word, Excel, Outlook) and claims processing systems required.
' Claims processing systems preferred.
' Other: Certified Fraud Investigator: Medical coding procedure expertise (CPT, ICD-10, HCPCS).
' Strong analytical, problem-solving, and decision-making abilities.
' Excellent verbal and written communication skills.
' Attention to detail, accuracy, and ability to handle confidential information.
' Certification in Coding and Medical Billing preferred.