POSITION SUMMARY/RESPONSIBILITIES 

Oversees the Special Investigations Unit (SIU) and is dedicated solely to the Texas Medicaid and CHIP programs to direct oversight of the SIU and Fraud, Waste, and Abuse activities.  Responsible for the investigative process related to fraud and abuse. Research may relate to eligibility, claims payment, benefits, prior authorization/referrals, pharmacy review, provider and member contract review, verification, etc.  Responsible for conducting and reviewing audits to assess the quality of coding and documentation to ensure compliance with federal and state laws and regulations.  Coordinates decisions regarding resolution of fraud and abuse issues and appeals with department and health plan leadership.  Responsible for researching and compiling documentation that may be reported to external regulatory and law enforcement agencies. Research and audit for accurate provider and facility payments. Tracks recovery of over payments.  Assists providers, employees and contractors with the Community First Health Plan’s (Community First) anti-fraud program and with policies and procedures concerning the Special Investigations Unit.  Conducts routine education programs for staff and physicians to communicate findings from coding and documentation audits.

EDUCATION/EXPERIENCE

            Certification from AAPC or AHIMA as a Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Registered Health Information Administrator (RHIA), or a Registered Health Information Technician (RHIT) is required.  A related field with at least three years' experience performing various claims validation reviews in a multi-specialty setting is required.  Expert knowledge of ICD, CPT, HCPCS coding classifications and DRG, APC and ASC payment methodology. Five years' experience in the HMO/Managed Care or health plan environment is required with emphasis on claims, contracting, appeals and grievances.  Three years' experience in interpretation of Texas Medicaid Managed Care regulations, Texas Department of Insurance regulations, and/or HHSC OIG Medicaid Managed Care SIU preferred.  Experience with anti-fraud detection and prevention preferred.  Experience with and knowledge of PC database systems is required.  Two years' supervisory experience is preferred.