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 Manager, SIU manages a team 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 determines correct coding, review claims, review medical records, and billing data from all types of healthcare providers for aberrant billing patterns and is responsible for 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. The Manager, SIU develops, implements and manages strategic FWA activities by maintaining state and federal requirements and monitoring trends and schemes and is accountable for all investigations conducted by the team and provides 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.

MINIMUM QUALIFICATIONS:

Education/Specialized Training/Licensure: Bachelor's degree required. Certification (Accredited Healthcare Fraud Investigator and/or Certified Fraud Examiner, etc.) required or eligible to obtain within 1 year of employment. Graduate degree preferred. 

Work Experience (Years and Area): 5 years of conducting comprehensive healthcare insurance investigations, and interacting with state, federal, and local law enforcement agencies. 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. Knowledge of medical terminology and/or experience with CPT and ICD-10 coding preferred.

Management Experience (Years and Area): 3 years of Healthcare SIU managerial/supervisory experience

Software Operated: MS Office applications (Word, Excel, Outlook, PowerPoint).

SPECIAL REQUIREMENTS: (Check Applicable Areas)

Communication Skills:
Above Average Verbal (Heavy Public Contact) 
Writing /Composing: Correspondence / Reports 
Other Skills: Analytical, CRT, Mathematics, Medical Terminology, Research, Statistical, MS Word, MS Excel 
Advanced Education: Advanced Training Specialty: Accredited Healthcare Fraud Investigator and/or Certified Fraud Examiner, etc. or eligible to obtain within the first year of employment.  
Bachelor's Degree Major: Required
Master's Degree Major: Preferred

Work Schedule: Flexible

Other Requirements: 
Excellent leadership, team building, and strategic thinking skills.
Proven project planning and management skills with previous supervisory experience.
Ability to analyze and interpret financial data in order to coordinate the preparation of financial records.
Ability to prepare and present training sessions. 
Excellent written and verbal communication skills.
Likes to focus on the 'big picture' and thrives in fast paced, multi-project work environment.
Strong organizational, interpersonal, and problem-solving skills

RESPONSIBLE TO: Director 

EMPLOYEE SUPERVISED: Professional

Application Instructions

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