Job Description

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.

Skills / Requirements

JOB SUMMARY: The Senior SIU Investigator performs reviews of claim lines flagged by Community's SIU and Community's SIU Contractor. The SIU Senior Investigator work assignments involving high level, moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. This position routinely handles cases that are sensitive, complex and/or high profile, involving multi-disciplinary provider groups, or cases involving multiple perpetrators or intricate healthcare fraud schemes.  The Senior SIU Investigator cooperates with federal, state, and local law enforcement agencies in the investigation and prosecution of FWA matters.



Education/Specialized Training/Licensure: Bachelor's degree required. Certification in Coding and Medical Billing, Accredited Health Care Fraud Investigator (AHFI) or Certified Fraud Investigator (CFE) certification required, or eligible to obtain within 1 year of employment.

Work Experience : Five (5) years fraud, waste, and abuse investigative experience in the healthcare industry and / or coding in the medical industry directly related to determining appropriate diagnosis, procedure and other codes used in billing for services, utilization management, medical record auditing.

Software Operated: Microsoft Office (Word, Excel, Outlook)

Other Requirements:
- Experience training others within a SIU on FWA investigations processes preferred.
- Solid Knowledge of Medicare, Medicaid and commercial investigations and coding practices.

1. Communication Skills:
Above Average Verbal (Heavy Public Contact)
Exceptional Verbal (e.g., Public Speaking)
Writing /Composing: Correspondence / Reports

2. Other Skills: Medical Terminology, Research, MS Word, MS Excel

3. Advanced Education:

Advanced Training Specialty: Certification in Coding and Medical Billing, and Accredited Healthcare Fraud Investigator and/or Certified Fraud Investigator required.


Application Instructions

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