Location:

Calmont Operations Building

Department:

Compliance

Shift:

First Shift (United States of America)

Standard Weekly Hours:

Summary:

Responsible for supporting the prevention, detection, investigation, reporting, and when appropriate, recovery of money related to Texas Medicaid Provider fraud, waste, and abuse within Cook Childrens Health Plans provider network, members, and staff. Duties include generating accurate and timely analysis and reports to support the SIU preliminary investigation and medical record audit to identify fraud, waste, and abuse. The position may also work with other internal departments, including Compliance, Corporate Legal Counsel, and the Health Plan Medical Director for additional oversight and compliance with Texas Medicaid Fraud, Waste and Abuse regulatory guidelines. Responsibilities include importing, transforming, and validating data from the SIU team for decision-making purposes on identifying provider fraud or provider education.

Additional Information:

Education & Experience:

Bachelor's degree required.
Must have a minimum of 3 years Medicaid or CHIP fraud, waste and abuse investigatory experience.

Knowledge, Skills & Abilities:

Extensive knowledge of claim processing with advanced knowledge of medical benefits, medical terminology and coding.
Proficient in ICD-9/ICD-10 and CPT coding.
Knowledge of government programs (Medicaid, & CHIP).
One year experience conducting data analysis and reporting.
Must have Microsoft Office skills with Word and Excel.

Certification/Licensure:

CFE through ACFE or NHCAA required or obtain the certification within two years of employment.

About Us:

Cook Children's Health Plan

Cook Children's Health Plan provides vital coverage to nearly 120,000 people in low-income families who qualify for government-sponsored programs in our six county service region. Cook Children's Health Plan provides health coverage for CHIP, CHIP Perinatal, STAR (Medicaid) and STAR Kids Members in the Tarrant county service area. The counties we serve includes Tarrant, Johnson, Denton, Parker, Hood and Wise.

Cook Children's is an equal opportunity employer. As such, Cook Children's offers equal employment opportunities without regard to race, color, religion, sex, age, national origin, physical or mental disability, pregnancy, protected veteran status, genetic information, or any other protected class in accordance with applicable federal laws. These opportunities include terms, conditions and privileges of employment, including but not limited to hiring, job placement, training, compensation, discipline, advancement and termination.