Manager Special Investigation Unit - Community Health Choice
Harris Health System
Location: Houston, Texas
Type: Full Time
Internal Number: 156917
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.
1. 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. 2. 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. 3. Management Experience (Years and Area): 3 years of Healthcare SIU managerial/supervisory experience 4. Software Operated: MS Office applications (Word, Excel, Outlook, PowerPoint).
SPECIAL REQUIREMENTS: (Check Applicable Areas)
1. Communication Skills: Above Average Verbal (Heavy Public Contact) Writing /Composing: Correspondence / Reports
2. Other Skills: Analytical, CRT, Mathematics, Medical Terminology, Research, Statistical, MS Word, MS Excel
3. 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
4. Work Schedule: Flexible
5. 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
Please be advised: Effective Wednesday, September 1st, 2021, with the exception of those who receive an approved exemption, all new hires must provide proof of vaccination against COVID-19 or receive the first dose of a COVID-19 vaccine by the second Friday of employment.
The Harris Health System is a fully integrated healthcare system that cares for all residents of Harris County, Texas. We are the first accredited healthcare institution in Harris County to be designated by the National Committee for Quality Assurance as a Patient-Centered Medical Home, and are one of the largest systems in the country to achieve the quality standard. Our system includes 23 community health centers, five school-based clinics, a dental center and dialysis center, mobile health units, a rehabilitation and specialty hospital and two full-service hospitals.Ben Taub Hospital is a world renowned Level I Trauma Center with 586 licensed acute-care beds and provides a wide range of specialty care outpatient services. Lyndon B. Johnson Hospital is a 328 licensed bed acute-care hospital with a newly expanded Level III trauma center and a distinguished regional center for neonatal intensive care for high-risk deliveries.Harris Health is a teaching system for Baylor College of Medicine and The University of Texas Health Science Center at Houston (UTHealth). We train the next generation of healthcare providers on the latest medical procedures and technological breakthroughs.With... our fully integrated electronic medical records system, we offer patients the convenience and assurance that their medical history is accurate, safe and available when and where it is needed. Our Medical Home designation ensures that we offer a full range of preventive, specialty and acute care services for the entire family.