Manager, Special Investigations Unit

7 days ago

Houston, Texas, United States Texas Children's Hospital Full time
Job Title: Manager, Special Investigations Unit

We are seeking a highly skilled and experienced Manager to lead our Special Investigations Unit (SIU). The successful candidate will be responsible for overseeing the SIU and Fraud, Waste & Abuse (FWA) Program, ensuring compliance with contractual and regulatory requirements.

Key Responsibilities:
  • Coordinate with subcontractors to oversee investigations of Fraud, Waste & Abuse (FWA).
  • Manage a large fraud investigation caseload and investigate allegations relating to potential health care fraud perpetrated by Medicaid and commercial providers, vendors, and enrollees.
  • Provide internal and external case updates on the progression of investigations in coordination with SIU team members and other departments, including recommendations on further action and/or resolution, as needed.
  • Continually interface 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.
  • Implement processes and procedures to prevent, detect, investigate, and report FWA to appropriate regulatory agencies.
  • Provide inter-departmental input regarding controls for preventing and monitoring FWA issues.
  • Proactively identify trends and aberrant activity to generate leads for FWA investigations.
  • Perform special assignments related to FWA as assigned by the Director of Controls and Compliance.
  • Accountable for managing the day-to-day activities of the SIU Department, reporting directly to the Director of Controls and Compliance.
  • Develop and maintain outcome-focused SIU Policies & Procedures which are consistent with all applicable contractual and regulatory requirements.
  • Support 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.
  • Conduct comprehensive analysis of claim utilization data to prevent payment of fraudulent claims.
  • Assist with data mining activities using available tools and applications.
  • Develop and implement plans for operations in cases of prospective and retrospective fraud, waste, and abuse and overpayment recovery.
  • Provide periodic internal and external training to all staff and contractors on fraud, waste, and abuse.
  • Develop and maintain strong working relationships with company management, associates, and State regulators.
Requirements:
  • High School Diploma/GED or Bachelor's Degree preferred.
  • One of the following Certifications: EDUHRUSE, CPA: Certified Public Accountant, CFA: Certified Fraud Examiner, AHFI: NHCCA National Health Care Anti-Fraud Association, INT-POPC: Intermediate Peace Officer Proficiency Certificate.
  • 8 years' experience in fraud, waste & abuse (FWA) investigations or special investigations unit (SIU), including 1 year of experience working with Medicaid.

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