We are searching for a Senior SIU Investigator -- someone who works well in a fast-paced setting. In this position, you will assist the Director of Controls and Compliance and the Special Investigative Unit Manager in conducting investigations into suspected incidents of Fraud, Waste, and Abuse (FWA). This includes data mining for potential intakes, performing preliminary analysis on provider cases, and working on projects focused on preventing, detecting, and correcting fraud, waste, and abuse.

Job Duties & Responsibilities
•    Conducts Fraud, Waste and Abuse (FWA) and related compliance investigations.
•    Completes detailed and extensive investigations in adherence with organization’s procedures and best practices. Gather evidence and determine potential recoveries.
•    Independently develops and executes appropriate investigation strategy for assigned cases. Leads in-depth interviews of participants, witnesses or affected parties.
•    Researches and prepares cases for clinical and legal reviews.
•    Conducts reviews of flagged claims and suspected FWA, identifying opportunities for improving payment accuracy and preventing FWA.
•    Analyzes compliance and FWA cases for root cause, trends, and tracks data to translate findings and develop processes for improvement or investigation.
•    Prepares accurate, timely, unbiased, and detailed written reports and case summaries in compliance with corporate standard operating procedures and guidelines documenting investigative results.
•    Prepares referrals for preliminary investigations, including Requesting medical records, creating forms, reports and updating logs.
•    Facilitates the recovery of inappropriate payments from FWA matters.
•    Drafts recoupment letters for FWA findings.
•    Supports other investigators in SIU operations.
•    Trains SIU Investigator on Investigation procedures.
•    Maintains case management log with investigative notes, reports, and summaries.
•    Proactively collaborates with line of business personnel to generate referrals.
•    Partners with the federal and state agencies on data requests, projects, investigations, and meetings.
•    Communicates investigation outcomes to line of business personnel and partners to implement provider and other compliance/ SIU related edits when appropriate.
•    Maintains organization’s confidential information in accordance with corporate policies, as well as state and federal laws, rules, and regulations regarding confidentiality.

Skills & Requirements
•    High School Diploma or GED with preferred bachelor's degree
•    6 years’ experience in claims examination, adjusting, fraud detection, or investigations preferably in a healthcare environment
•    Preferred certification as an Accredited Health Care Fraud Investigator (AHFI) by the National Healthcare Anti-Fraud Association (NHCAA)

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.

Learn more about this Employer on their Career Site

Senior SIU (Claims Fraud) Investigator