Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:
* Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
* Children’s Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
* Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
* Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.
Improving Members’ experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.
Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.
Skills / Requirements

JOB SUMMARY:

The Special Investigation Unit Investigator performs reviews of claim lines flagged by Community’s SIU and Community’s SIU Contractor. The SIU investigator will assist the SIU manager in gathering information from internal and external partners for investigations and audits. The SIU investigator will coordinate with internal and external resources in determining the appropriateness of codes found in administrative and medical claims and develop reports of findings and recommendations for the SIU function.

1. Provide timely review and disposition of suspected case referrals, including determination on alleged up coding and our unbundling and communicate with internal and external sources as well as review claim lines flagged by SIU Contractor with do not pay recommendations.
2. Develops and present findings and recommendations regarding the appropriateness of diagnosis and procedure codes submitted on provider service claims, and supports overpayment during discussions with providers and Community’s Fraud, Waste and Abuse Committee.
3. Communicate review outcomes and the basis for them effectively and professionally with providers, CHS staff, Fraud Waste and Abuse Committee and other regulatory agencies such as The Office of Inspector General (OIG), Texas Attorney General.
4. Gathers and analyzes data from internal and external resources including claims, data, medical records, contracts, and public record information to determine if further action and an investigation needs to be performed.
5. Educates providers, suppliers, and pharmacies and administrative support staff at all levels on CMS, federal and state statutory, regulatory and contractual requirements, appropriate coding according to AMA guidelines, acceptable practice standards, and procedures for preventing and reporting potential fraud and abuse; Presents educational seminars on fraud and abuse awareness, detection and reporting to areas and departments as required.
6. Ensure the timely reporting of regulatory reports as needed.
7. Actively contributes to achievement of departmental goals, as identified in Department’s annual business plan, including specific departmental process improvement plans.
8. Demonstrates Harris Health and Community Health Choice values, including trust, integrity, mutual respect, diversity, responsiveness and caring service.
   Job Type: Full-time
   Pay: $57,600.00 - $72,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Day shift

Work Location: Hybrid remote in Houston, TX 7708