Senior Fraud Investigator

We are seeking a highly skilled Senior Fraud Investigator to oversee the Special Investigations Unit (SIU) and Fraud, Waste & Abuse (FWA) Program at Texas Children's Health Plan.

The ideal candidate will have 8 years of experience in fraud, waste & abuse investigations or special investigations unit, including 1 year of experience working with Medicaid.

Responsibilities will include:

• Managing a large fraud investigation caseload and investigating allegations relating to potential health care fraud perpetrated by Medicaid and commercial providers, vendors, and enrollees.
• Continually interfacing with members, vendors, pharmacies, providers, and other third parties via telephone, email, and on-site visits as needed to identify, further, and conclude ongoing investigations.

The Senior Fraud Investigator will also be responsible for:

• Implementing processes and procedures to prevent, detect, investigate, and report FWA to appropriate regulatory agencies.
• Providing inter-departmental input regarding controls for preventing and monitoring FWA issues.
• Accountable for managing the day-to-day activities of the SIU Department, reporting directly to the Director of Controls and Compliance.
• Developing and maintaining outcome-focused SIU Policies & Procedures which are consistent with all applicable contractual and regulatory requirements.
• Supporting internal and external SIU reviews as appropriate, including accurate tracking of case information and timely reporting as needed for internal and external audits, contractual requirements, and regulatory oversight.
• Conducting comprehensive analysis of claim utilization data to prevent payment of fraudulent claims.
• Assisting with data mining activities using available tools and applications.
• Developing and implementing plans for operations in cases of prospective and retrospective fraud, waste, and abuse and overpayment recovery.
• Providing periodic internal and external training to all staff and contractors on fraud, waste, and abuse.

A Bachelor's Degree is preferred, and the ideal candidate will have a Certified Fraud Examiner (CFA) certification and membership in the National Health Care Anti-Fraud Association (NHCCA).

Texas Children's Health Plan is an equal opportunity employer and welcomes applications from diverse candidates.