Nov 03, 2019

SIU Investigator / Health Insurance Investigator - Houston, TX

  • Professional Diversity Network
  • Houston, TX, USA
Full-Time Finance

Job Description

WellCare Health Plans

Reports To: SIU Manager., Compliance - SIU & Corporate Investigation

Dept.: Compliance - SIU & Corporate InvestigationLocation: Loop Central Drive, Houston, TX 77081

Position manages a heavy caseload and conducts healthcare fraud and abuse investigations as a member of the Special Investigations unit within the Corporate Compliance department. Identifies trends and aberrant activity to generate leads for fraud investigations and analyzes claims data to detect fraudulent activity. Testifies in criminal and civil matters as needed.

Essential Functions:

  • Manages large caseloads and investigates allegations and issues pertaining to potential health care fraud by providers or members.
  • Documents investigations, including preliminary and final case reports, for both internal tracking and regulatory reporting purposes.
  • Identifies trends and aberrant activity to generate leads for fraud investigations and analyzes claims data to detect fraudulent activity in a pro-active manner.
  • Supports senior compliance staff and legal counsel in all phases of investigation and litigation.
  • Prepares cases for referral to government agency and law enforcement.
  • Develops and maintains strong working relationships with associates and regulators.
  • Testifies in criminal and civil matters as needed.
  • Conducts special assignments as needed.
  • Trains associates regarding the activities of the Special Investigation Unit.
  • Performs other duties as assigned.
Additional Responsibilities:

Candidate Education:

  • Required A Bachelor's Degree in Related Field or
  • Required Other Associates with 4 years of applicable experience, or a High School/GED with 5 years of applicable experience may substitute for the Bachelors Degree
Candidate Experience:
  • Required 3 years of experience in Investigation or fraud-related investigations
  • Required Other reading, analyzing and interpreting State and Federal laws, rules and regulations
Candidate Skills:
  • Beginner Other In-depth knowledge of government programs, the managed care industry, Medicare, Medicate laws and requirements, federal, state, civil and criminal statutes.
  • Intermediate Ability to work in a fast paced environment with changing priorities
  • Intermediate Demonstrated organizational skills
  • Intermediate Ability to multi-task
  • Intermediate Demonstrated written communication skills
  • Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
Licenses and Certifications:
A license in one of the following is required:
  • Preferred Other Accredited Health Care Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE)
Technical Skills:
  • Preferred Intermediate Other Knowledge and understanding of claims processing systems and medical claims coding preferred
  • Required Intermediate Other Computer literate (MS Office, Excel, etc.)
  • Preferred Other second language

About us
Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.



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