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)
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)
Fraud Investigation Services Associate III
San Antonio, TX · On-site
$21/hr
Fraud Investigation Services Associate III Onsite - San Antonio, TX $21.00 per hour As a Fraud Investigation Services Associate III, you will be supporting our client's customers as the first point ...
Fraud Investigation Services Associate III
San Antonio, TX · On-site
$21/hr
Fraud Investigation Services Associate III Onsite - San Antonio, TX $21.00 per hour As a Fraud Investigation Services Associate III, you will be supporting our client's customers as the first point ...
Fraud Investigation Services Associate III Onsite - San Antonio, TX $21.00 per hour As a Fraud Investigation Services Associate III, you will be supporting our client's customers as the first point ...
Fraud Investigation Services Associate III Onsite - San Antonio, TX $21.00 per hour As a Fraud Investigation Services Associate III, you will be supporting our client's customers as the first point ...
Fraud Strategy Deposit Acquisition - Senior Associate
Plano, TX · On-site
$95 - $135/hr
As a Senior Associate within the Fraud Strategy Team, you will generate insightful analytics and provide recommendations concerning risk criteria development, implementation, operational controls ...
Fraud Strategy Deposit Acquisition - Senior Associate
Plano, TX · On-site
$95 - $135/hr
As a Senior Associate within the Fraud Strategy Team, you will generate insightful analytics and provide recommendations concerning risk criteria development, implementation, operational controls ...
Healthcare Fraud Attorney - Of Counsel
Dallas, TX · On-site
$55 - $65/hr
Join THEODORE P WATSON & ASSOCIATES as a Healthcare Fraud Attorney in Dallas, TX, where you will play a pivotal role in combating healthcare fraud.. We are looking for a passionate defense attorney ...
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Healthcare Fraud Attorney - Of Counsel
Dallas, TX · On-site
$55 - $65/hr
Join THEODORE P WATSON & ASSOCIATES as a Healthcare Fraud Attorney in Dallas, TX, where you will play a pivotal role in combating healthcare fraud.. We are looking for a passionate defense attorney ...
Clinical Fraud Investigator II Locations ... This role requires associates to be in-office 1-2 days per week, fostering collaboration and ...
Clinical Fraud Investigator II Locations ... This role requires associates to be in-office 1-2 days per week, fostering collaboration and ...
Our associates celebrate lives. We celebrate our associates. Conducts criminal and fraud investigations while enforcing criminal laws and institutional regulations that promote the protection and ...
Our associates celebrate lives. We celebrate our associates. Conducts criminal and fraud investigations while enforcing criminal laws and institutional regulations that promote the protection and ...
Our associates celebrate lives. We celebrate our associates. Conducts criminal and fraud investigations while enforcing criminal laws and institutional regulations that promote the protection and ...
Our associates celebrate lives. We celebrate our associates. Conducts criminal and fraud investigations while enforcing criminal laws and institutional regulations that promote the protection and ...
Senior Program Lead, Digital Fraud & Abuse
Dallas, TX · On-site
$120K - $260K/yr
... associates and applicants.
Senior Program Lead, Digital Fraud & Abuse
Dallas, TX · On-site
$120K - $260K/yr
... associates and applicants.
Fraud Call Center Representative
San Antonio, TX · On-site
$16.75/hr
Fraud Call Center Representative - Onsite (San Antonio, TX): Are you passionate about helping ... About Us Through our dedicated associates, Conduent delivers mission-critical services and ...
Fraud Call Center Representative
San Antonio, TX · On-site
$16.75/hr
Fraud Call Center Representative - Onsite (San Antonio, TX): Are you passionate about helping ... About Us Through our dedicated associates, Conduent delivers mission-critical services and ...
Fraud Call Center Representative - Onsite (San Antonio, TX): Are you passionate about helping ... Through our dedicated associates, Conduent delivers mission-critical services and solutions on ...
Fraud Call Center Representative - Onsite (San Antonio, TX): Are you passionate about helping ... Through our dedicated associates, Conduent delivers mission-critical services and solutions on ...
Our associates celebrate lives. We celebrate our associates. Conducts criminal and fraud investigations while enforcing criminal laws and institutional regulations that promote the protection and ...
Quick apply
Our associates celebrate lives. We celebrate our associates. Conducts criminal and fraud investigations while enforcing criminal laws and institutional regulations that promote the protection and ...
Our culture in the Risk Management and Fraud Center of Excellence emphasizes innovative thinking, challenging the status quo, and striving to be best-in-class. Job Responsibilities * Data ...
Our culture in the Risk Management and Fraud Center of Excellence emphasizes innovative thinking, challenging the status quo, and striving to be best-in-class. Job Responsibilities * Data ...
Our culture in the Risk Management and Fraud Center of Excellence emphasizes innovative thinking, challenging the status quo, and striving to be best-in-class. Job Responsibilities * Data ...
Our culture in the Risk Management and Fraud Center of Excellence emphasizes innovative thinking, challenging the status quo, and striving to be best-in-class. Job Responsibilities * Data ...
Our culture in the Risk Management and Fraud Center of Excellence emphasizes innovative thinking, challenging the status quo, and striving to be best-in-class. Job Responsibilities * Data ...
Our culture in the Risk Management and Fraud Center of Excellence emphasizes innovative thinking, challenging the status quo, and striving to be best-in-class. Job Responsibilities * Data ...
Asset Protection Associate - Richland Mall
Waco, TX · On-site
$14.75 - $19.50/hr
Reports suspected fraud (i.e., credit / check and refund fraud) and infractions of company policy ... Proactively identifies potential acts of theft and fraud by observing associate/customer activity ...
Asset Protection Associate - Richland Mall
Waco, TX · On-site
$14.75 - $19.50/hr
Reports suspected fraud (i.e., credit / check and refund fraud) and infractions of company policy ... Proactively identifies potential acts of theft and fraud by observing associate/customer activity ...
Asset Protection Associate - Killeen Mall
$14.75 - $19.75/hr
Reports suspected fraud (i.e., credit / check and refund fraud) and infractions of company policy ... Proactively identifies potential acts of theft and fraud by observing associate/customer activity ...
Asset Protection Associate - Killeen Mall
$14.75 - $19.75/hr
Reports suspected fraud (i.e., credit / check and refund fraud) and infractions of company policy ... Proactively identifies potential acts of theft and fraud by observing associate/customer activity ...
Asset Protection Associate - Killeen Mall
$14.75 - $19.75/hr
Reports suspected fraud (i.e., credit / check and refund fraud) and infractions of company policy ... Proactively identifies potential acts of theft and fraud by observing associate/customer activity ...
Asset Protection Associate - Killeen Mall
$14.75 - $19.75/hr
Reports suspected fraud (i.e., credit / check and refund fraud) and infractions of company policy ... Proactively identifies potential acts of theft and fraud by observing associate/customer activity ...
Asset Protection Associate - Parkdale Mall
Beaumont, TX · On-site
$14.50 - $18.13/hr
Reports suspected fraud (i.e., credit/check and refund fraud) and infractions of company policy to ... Proactively identifies potential acts of theft and fraud by observing associate/customer activity ...
Asset Protection Associate - Parkdale Mall
Beaumont, TX · On-site
$14.50 - $18.13/hr
Reports suspected fraud (i.e., credit/check and refund fraud) and infractions of company policy to ... Proactively identifies potential acts of theft and fraud by observing associate/customer activity ...
OAG - Medicaid Fraud Control Unit | Sergeant | 26-0228
Houston, TX · On-site
$7.4K/mo
Sixty credit hours from an accredited college or university; may substitute an associate's or ... Knowledge of TCOLE training requirements and healthcare fraud investigation training needs
OAG - Medicaid Fraud Control Unit | Sergeant | 26-0228
Houston, TX · On-site
$7.4K/mo
Sixty credit hours from an accredited college or university; may substitute an associate's or ... Knowledge of TCOLE training requirements and healthcare fraud investigation training needs
Fraud Associate information
See Texas salary details
$8.29 - $9.85
3% of jobs
$9.85 - $11.42
8% of jobs
$11.42 - $12.99
12% of jobs
$13.09 is the 25th percentile. Wages below this are outliers.
$12.99 - $14.56
28% of jobs
$14.56 - $16.13
15% of jobs
$17.42 is the 75th percentile. Wages above this are outliers.
$16.13 - $17.69
11% of jobs
$17.69 - $19.26
8% of jobs
$19.26 - $20.83
5% of jobs
$20.83 - $22.40
4% of jobs
$22.40 - $23.96
3% of jobs
$23.96 - $25.53
2% of jobs
$8
$15
$25
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Clinical Special Investigations Unit Investigator- Health Plan
Dallas, TX • On-site
Part-time
Re-posted 29 days ago
Parkland Health and Hospital System rating
8.1
Based on 91 frontline employees who took The Breakroom Quiz
65th of 893 rated healthcare providers
Job description
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.
Requisition ID: 988265
What Parkland Health and Hospital System employees say
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About Parkland Health and Hospital System
Sourced by ZipRecruiter
Parkland Health and Hospital System, based in Dallas, TX, US, is a reputed entity in the healthcare industry. Accessible through their website parklandhealth.org, this distinguished organization operates within the public sector, primarily providing medical care and services. Parkland Health was founded with a mission to take healthcare to people who need it the most and ever since its inception it has staunchly adhered to this principle. The hospital is acknowledged for its unyielding dedication to patient care, its world-class staff, and its innovative medical breakthroughs. Alongside its traditional healthcare offerings, Parkland also provides specialized services such as burn treatment and poison control, cementing their position as a comprehensive provider of critical care.
Industry
Hospitals
Company size
10,000+ Employees
Headquarters location
Dallas, TX, US