Special Investigations Unit Investigator - PCHP

Interested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and communities entrusted to our care. By joining Parkland, you become part of a diverse healthcare legacy that’s served our community for more than 125 years. Put your skills to work with us, seek opportunities to learn and join a talented team where patient care is more than a job. It’s our passion.

Primary Purpose

The purpose of the Parkland Community Health Plan (PCHP) Special Investigations Unit is to implement an effective compliance program that includes prevention, investigation and pursuit of fraud, waste, and abuse violations. The SIU Investigator ensures PCHP’s accountability for compliance by overseeing, follow-up and resolution of investigations in partnership with state and federal programs.

Minimum Specifications

Education

• Bachelor’s degree is required.

Experience

• Five years Medicaid or CHIP Fraud, Waste, and Abuse investigatory experience or related experience.
• Experience in provider education, a managed care organization and in medical record auditing is preferred.

Certification/Registration/Licensure

• Must be currently certified and in good standing or obtain certification within twelve (12) months of hire with one of the following: Health Care Anti-Fraud Associate (HCAFA), Accredited Health Care Fraud Investigator (AHFI), Association of Certified Fraud Examiners (CFE), or National Health Care Anti-Fraud Association (NHCAA)

Skills or Special Abilities

• Knowledge of health care programs and policies, and experience interpreting regulatory requirements.
• Communicate clearly and concisely, both verbally and in writing, and has strong presentation skills.
• Demonstrate strong organizational, analytical, problem solving, and project management skills.
• Ability to build consensus on strategies and messages among peers and stakeholders.
• Adapt to constantly changing priorities in managing various projects simultaneously.
• Work independently and as a team member on assigned projects.
• Excellent organization, facilitation, written and oral communication skills.
• High degree of interpersonal skills, influence, negotiations, and problem-solving abilities.
• Ability to work cross functionally and collaborate with other departments and organizations on compliance matters.
• High proficiency in Microsoft Excel, Word, and Access applications.
• Must be able to frequently problem solve, make decisions, interpret data, organize, and analyze workflow, write, plan, and use simple arithmetic.

Responsibilities

1. Responsible for referral intake process and developing leads presented to the SIU to assess and determine whether potential fraud, waste, or abuse is corroborated by evidence.
2. Conducts preliminary investigations, along with witness interviews, within the mandated period of time required by either state and/or federal contracts and/or regulations.
3. Conducts non-medical/non-coding related extensive investigations and makes determinations as to whether the investigation and/or audit identified potential fraud, waste, or abuse.
4. Prepares detailed preliminary and extensive investigation referrals to state and/or federal regulatory and/or law enforcement agencies when potential fraud, waste, or abuse is identified as required by regulatory and/or contract requirements.
5. Interacts with regulatory and/or law enforcement agencies regarding case investigations.
6. Conducts detailed claims analysis and prepares audit results letters to providers when overpayments are identified.
7. Conducting root cause analysis and communicating systems, policy or other control gaps identified to operating and/or audit management as well as Medicaid Compliance, where appropriate.
8. Contributing to educational fraud awareness training efforts for PCHP employees and others to deter and minimize health care fraud losses.
9. Responds to Requests for Information (RFIs) from National Benefit Integrity MEDIC, U.S. Office of Personnel Management Office of the Inspector General (OPM OIG), State Departments of Insurance (DOI), and other law enforcement agencies, as appropriate.

Job Accountabilities

1. Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of PCHP.
2. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
3. Maintains knowledge of applicable rules, regulations, policies, laws, and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding.

Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status. As part of our commitment to our patients and employees’ wellness, Parkland Health is a tobacco and smoke-free campus.