Clinical Special Investigations Unit Investigator- Health Plan

PCHP- Parkland Community Health Plan

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 Clinical 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 in Nursing or a related field is required.

Experience

• Four years of related clinical experience in the field of obtained license.
• Three years Medicaid or CHIP Fraud, Waste, and Abuse investigatory experience.
• Experience in provider education, a managed care organization or medical record auditing is preferred.

Equivalent Education and/or Experience

• Four years of experience in Medicaid or Chip utilization review may be substituted for the 3 years of Medicaid or CHIP Fraud, Waste, and Abuse investigatory experience requirement.
• Licensed Vocational Nurse (LVN) with four years of Medicaid or CHIP Fraud, Waste, and Abuse investigatory experience may be substituted for the required education and clinical experience requirement.

Certification/Registration/Licensure

• Must have a current, unrestricted license in the State of Texas (or compact license) of at least one of the following: RN, LPC, LCSW, LMHC, LVN, PT, OT or ST license.
• 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

• Performs complex retrospective and prepayment reviews of medical records to identify potential abuse and fraud and inappropriate billing practices.
• Investigates, analyzes, and identifies provider billing patterns to recommend payment based on medical records, claim history, billing codes, regulatory and state guidelines, and policies
• Prepares summary of findings and recommend next steps for providers.
• Identifies preventative measures and recommends changes to internal policies and procedures and/or provider practices to prevent future fraudulent and erroneous practices.
• Consults investigators to identify abuse and fraud by utilizing clinical and coding expertise to analyze patterns in billing activities.
• Performs onsite audits in conjunction with investigators and/or managers.
• Reviews providers' claims history, licensure, and specialty. Assesses providers by interviewing staff, examining the facility and equipment, and reviewing medical records.
• Provides instructions to the claims department for prepayment reviews.
• Assists SIU Manager as needed with training new hires, answering questions from employees, auditing work of non-clinical investigators and assisting with provider education.
• Audits medical records to identify inappropriate billing practices and determine medical necessity through extensive review of claims data, medical records, corporate policies, state/federal policies, and the interpretation of practice standards.
• Consults with Chief Medical Officer and other PCHP personnel to clarify medical necessity and billing appropriateness.
• Refers cases to applicable internal department such as Quality Management, Legal, Provider Relations and Health Services Delivery.
• 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.