• Job Description

  Req#: JR-111901

  Location:

  Calmont Operations Building

  Department:

  Compliance

  Shift:

  First Shift (United States of America)

  Standard Weekly Hours:

  40

  Summary:

  Additional Information:

  Responsible for supporting the Cook Children’s Health Plan’s SIU Manager in the prevention, detection, investigation, reporting, and when appropriate, recovery of money related to Texas Medicaid Fraud, Waste, and Abuse Program regulations. Duties include generating accurate and timely analysis and reports to support the SIU preliminary and full-scale investigations and medical record audits to identify possible fraud, waste, and abuse. The position may also work with other internal departments, including Compliance, Corporate Legal Counsel, and the Health Plan Medical Director for additional guidance. Responsibilities include importing, transforming, and validating data from the SIU analytics tool for decision-making purposes on identifying potential fraud.

  Education & Experience

  • Bachelor’s degree required.

  • Must hold credentials such as certification from the Association of Certified Fraud Examiners as a Certified Fraud Examiner (CFE), an accreditation from the National Health Care Anti-Fraud
    Association as an Accredited Health Care Fraud Investigator (AHFI)

  OR

  • Have previous law enforcement experience with a minimum of 3 years Medicaid or CHIP fraud, waste and abuse investigatory experience.

  Knowledge, Skills & Abilities

  • Knowledge of claim processing with advanced knowledge of medical benefits, medical terminology and coding.

  • Proficient in ICD-10 and CPT coding.

  • Knowledge of government programs (Medicaid & CHIP).

  • Knowledge of data analysis and reporting.

  • Must have Microsoft Office skills with Word and Excel.

  Licensure, Registration, and/or Certification

  • Certified Fraud Examiner or an Accredited Health Care Fraud Investigator required.

  About Us:

  Cook Children's Health Plan

  Cook Children's Health Plan provides vital coverage to nearly 120,000 people in low-income families who qualify for government-sponsored programs in our six county service region. Cook Children's Health Plan provides health coverage for CHIP, CHIP Perinatal, STAR (Medicaid) and STAR Kids Members in the Tarrant county service area. The counties we serve includes Tarrant, Johnson, Denton, Parker, Hood and Wise.

  Cook Children’s is an equal opportunity employer. As such, Cook Children’s offers equal employment opportunities without regard to race, color, religion, sex, age, national origin, physical or mental disability, pregnancy, protected veteran status, genetic information, or any other protected class in accordance with applicable federal laws. These opportunities include terms, conditions and privileges of employment, including but not limited to hiring, job placement, training, compensation, discipline, advancement and termination.

• About the company

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