Assistant Director of the Special Investigations Unit - Health Plan

We are searching for an Assistant Director of the Special Investigations Unit TCHP - someone who works well in a fast-paced setting. In this position, you will oversee the Special Investigations Unit (SIU) and Fraud, Waste & Abuse (FWA) Program in compliance with contractual and regulatory requirements. Oversees case management, case investigation, overpayment recoveries, reporting of investigations to regulatory agencies; response to government requests for information related to FWA; facilitates compliance with state and federal FWA requirements; develops and maintains employee education; and identifies new recovery opportunities, goals and sound practices. Assists with the design of the overall programs, the yearly work plans approved by the board, and will have direct interaction with HHSC and executives.

Think you’ve got what it takes

Skills & Requirements

Being fully vaccinated against COVID-19, including any booster dose(s) of the COVID-19 vaccine recommended by the Centers for Disease Control when eligible, is required for all employees at Texas Children’s unless approved for a medical or religious exemption

• Required Bachelor's Degree. With a bachelor’s degree in Healthcare administration, accounting, auditing, business administration, information systems, research/data analysis, or other healthcare or business-related field of study and a Master's Degree
• Certified Insurance Fraud Investigator (CIFI), Certified Fraud Examiner (CFA), and/or Certified Compliance & Ethic Professional (CCEP) preferred
• Required 6 years’ experience in audit, compliance, fraud, waste & abuse (FWA) investigations, billing, and/or special investigations unit (SIU) experience, including at least six (6) months of formal management/supervisory experience. With a preferred 1 year experience working with Medicaid

Job Duties & Responsibilities

• Directs and oversees investigations related to Fraud, Waste & Abuse. Coordinates with subcontractors on overseeing investigations of Fraud, Waste & Abuse (FWA). Manages a large fraud investigation caseload and investigates allegations relating to potential health care fraud perpetrated by Medicaid and commercial providers, vendors and enrollees
• Directs and oversees the Special Investigation Unit (SIU). Accountable for managing the day-to-day activities of the SIU Department, reporting directly to the Director of Controls and Compliance. Develops and maintains outcome-focused SIU Policies & Procedures that are consistent with all applicable contractual and regulatory requirements
• TCHP SIU department Annual Work Plan. Create annual work plans for the TCHP SIU department to be approved by the Audit & Compliance Board of Trustees. Ensures appropriate allocation of existing resources for adequate coverage and completion of the Annual Work.
• Collaborates with other departments within TCHP and outside vendors to ensure the success of
• the TCHP SIU program. Continually interfaces with members, vendors, pharmacies, providers and other third parties via telephone, e-mail, and on-site visits as needed to identify, further, and conclude ongoing investigations. Provides inter-departmental input regarding controls for preventing and monitoring FWA issues.