Clinical Special Investigations Unit Investigator- Health Plan
Parkland Community Health Plan, Inc.
- # Clinical Special Investigations Unit Investigator- Health PlanApplylocations: Mockingbird Towers 4th FLRtime type: Full timeposted on: Posted Todayjob requisition id: 988265**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.
- J-18808-Ljbffr Parkland Community Health Plan, Inc.
Vacancy posted 3 days ago
Similar jobs that could be interesting for youBased on the Clinical Special Investigations Unit Investigator- Health Plan in Dallas, TX vacancy
$5,368.08 - $6,779.25 per month
...alert: Join the Texas Health and Human Services... ...defined benefit pension plan, generous time off benefits... ...Operations Investigator IV Job Title: Investigator... ...intake process. Utilizes specialized applications to determine... ...assigned to maintain unit and UOU operations....UnitHealth InsuranceFull timeTemporary workPart timeCasual workWork at officeLocal areaRemote workFlexible hoursShift workWeekend workAfternoon shift- ...Clinical Fraud Investigator II Locations: This role requires associates to... ...Collaborates with the Special Investigation Unit and other internal areas... ...be advised that Elevance Health only accepts resumes for... ...) +match, stock purchase plan, life insurance, wellness...UnitTemporary workWork at officeLocal area2 days per week1 day per week
Elevance Health
Grand Prairie, TX4 days ago - ...with Allied Universal® Compliance and Investigation Services. Allied Universal®... ...Description Allied Universal® is hiring a Special Investigations Unit (SIU) Investigator. Special Investigations... ...Independently develop a strategic plan to achieve assignment objectives, ensuring...UnitWork at officeLocal area
- ...Description Specialization: Cardiology Adult Congenital... ...and interest in clinical/outcomes research... ...for medical, behavioral health, prescription drugs, dental... ...Life insurance ~401(k) plan with employer matching... ...Intensive Care Unit (NICU) in North Texas...UnitHealth InsuranceFull timeFlexible hours
- ...Description Specialization: Pediatric Critical Care... ...improvement, education, and clinical innovation.... ...for medical, behavioral health, prescription drugs, dental... ...insurance ~401(k) plan with employer matching... ...bed cardiac step-down unit, supported by a robust...UnitHealth InsuranceFull timeFlexible hours
- ...vital voices surveys, and units of distinction. We... ...experience and positive clinical outcomes. As a Float Pool... ...condition, treatment plan, medications, possible... ...package that supports the health, life, career, and... ...Hospitals are hospitals for specialized advanced cardiovascular...UnitHealth InsuranceFull timeTemporary workWork from homeFlexible hoursShift workNight shift
Medical City Healthcare
Dallas, TX3 days ago $18 per hour
...Ethos Risk Services is a leading insurance claims investigation and medical management company, specializing in surveillance and fraud detection. At the forefront... ..., we offer a mileage reimbursement program. Health Insurance/Retirement: Medical, Dental Vision, Life/...Health InsuranceHourly payFull timeLocal areaNight shiftWeekend workEthos
Syracuse, NY5 days ago$30k
...cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as... ...Operating Room Rounding with unit leaders, including... ...Hospitals are hospitals for specialized advanced cardiovascular... ...technology. We offer clinical trials. You will have...UnitHealth InsuranceFull timeTemporary workPart timeRelocation packageMonday to FridayFlexible hoursShift workMedical City Healthcare
Dallas, TX2 days ago- ...Clinical Nurse Coordinator (CNC) Stroke response times... ...As a national learning health system, we're... ...of all functions in the unit/department during the designated... .... The available plans and programs include:... ...Hospitals are hospitals for specialized advanced cardiovascular...UnitHealth InsuranceHourly payFull timeTemporary workFlexible hoursShift workNight shift
- ...Project Archaeologist Principal Investigator - North Central Texas... ...excavating shovel tests and test units, screening soil, carrying field... ...consulting firm planned, designed, engineered, constructed... ...plansEmployee Stock Ownership Plan (ESOP)Health Savings Account (HSA)529...UnitTemporary workWork at officeRelocation
- ...critically ill patients in the units.At Baylor Scott & White Health, we promote well-being... ...issues, creating care plans, and assessing patient responses... ..., will conduct detailed clinical assessments, prioritize... ...of an Accredited Program Specialized field of study should be...UnitHealth InsuranceWork at officeImmediate start
Netpace
Irving, TX1 day ago - ...patient care delivery by the health care team. Using the... ...an individualized plan of care, and evaluates... ...Location: Hospitalist A Unit Shift Full-Time Nights... ...Placement None Skills Or Special Abilities Provides care... ...multidisciplinary plan of care, and clinical area-specific standards...UnitHealth InsuranceFull timeTemporary workShift workNight shift
Parkland Health
Dallas, TX4 days ago - ...part of Baylor Scott & White Health, is a major patient care, teaching... ...the top 50 programs in the United States. Baylor Dallas is... ...access points, a quality health plan and an award-winning research... ...patients, Strokes, specialized spine, Neurovascular surgeries...UnitHealth InsuranceFull timeImmediate startRelocation packageShift work
Star Nursing
Dallas, TX1 day ago - ...Medical Center's newest Unit - Roberts 17 FT 7:00pm... ...patient care standards and clinical culture of this new... ...at Baylor Scott & White Health we promote the well-... ...issues, creating care plans, and assessing patient... ...an Accredited Program Specialized field of study should be...UnitHealth InsuranceWork at officeImmediate start
Baylor Scott & White Health
Irving, TX2 days ago - ...RegularLanguage Fluency: English (Required)Work Shift:1st shift (United States of America)Please review the following job description:... ...Specific activities may change from time to time. 1. Executes sales plan, develops strong partnership and collaboration with line of...UnitHealth InsuranceFull timePart timeShift workDay shift
$121.2k - $225.2k
...employees with curated development plans that foster growth and... ....Job SummaryThe Director of Special Investigations will lead the Special... ...Enterprise-Wide Intelligence Unit, which is primarily responsible... ...FBI, the U.S. Department of Health and Human Services (HHS), and...UnitFull time- ...critically ill patients in the units. RN ICU Nights Join Baylor... ...part of Baylor Scott & White Health System. Established in 1964 as... ...access points, a quality health plan and an award-winning research... ...Grad of an Accredited Program Specialized field of study should be nursing...UnitHealth InsuranceFull timeImmediate startRelocation packageNight shift
Star Nursing
Irving, TX3 days ago - ...through the cracks. We specialize in supporting children... ...neurobehavioral, and rehabilitation units for a full continuum of... ...role requires advanced clinical reasoning,... ...progress and adjust treatment plans based on... ...nursing, and behavioral health teamsParticipate in treatment...UnitHealth InsuranceRelief
Nexus Health Systems
Dallas, TX1 day ago - ...Description Specialization: Obstetrics and Gynecology Job Summary... ...for medical, behavioral health, prescription drugs, dental and... ...~ Life insurance ~401(k) plan with employer matching contributions... ...Cardiac Intensive Care Unit and 12-bed step down unit ~...UnitHealth InsuranceFull timePrivate practiceFlexible hours
- ...- 12 General Medicine Unit Primary Purpose The RN... ...patient care delivery by the health care team. Using the... ...an individualized plan of care, and evaluates... ...Training Network Skills Or Special Abilities Provides care... ...multidisciplinary plan of care, and clinical area specific standards...UnitHealth InsuranceTemporary workShift work
Parkland Health
Dallas, TX3 days ago - ...- 12 General Medicine Unit Primary Purpose The RN... ...patient care delivery by the health care team. Using the... ...an individualized plan of care, and evaluates... ...Training Network Skills Or Special Abilities Provides care... ...multidisciplinary plan of care, and clinical area specific standards...UnitHealth InsuranceTemporary workShift work
Parkland Health
Dallas, TX3 days ago - ...part of Baylor Scott & White Health, is a major patient care, teaching... ...the top 50 programs in the United States. Baylor Dallas is honored... ...points, a quality health plan and an award-winning research... ...survival when care is provided by specially trained transplant RNs, so we...UnitHealth InsuranceFull timeImmediate startRelocation packageFlexible hoursShift workNight shift
Baylor Scott & White Health
Highland Park, TX3 days ago - ...- 12 General Medicine Unit Primary Purpose The RN... ...patient care delivery by the health care team. Using the... ...an individualized plan of care, and evaluates... ...Training Network Skills Or Special Abilities Provides care... ...multidisciplinary plan of care, and clinical area specific standards...UnitHealth InsuranceTemporary workShift work
Parkland Health
Dallas, TX3 days ago - ...Swan, AIBP, etc. This unit operates as a Cardiac Universal... ...Baylor Scott & White Health we promote the well-... ...401(k) savings plan with dollar-for-dollar... ...an RN, conduct detailed clinical assessments and prioritize... ...an Accredited Program Specialized field of study should be...UnitHealth InsuranceWork at officeImmediate startRelocationRelocation packageShift workNight shiftRotating shift
Baylor Scott & White Health
Irving, TX2 days ago - ...orders for supplies distributed to Parkland units, the pharmacy, sterile processing,... ...Required Tests For Placement None Skills Or Special Abilities Must be able to read and write... ...and federal, state, and private health plans. Seeks advice and guidance as necessary...UnitHealth Insurance
$2,843 per week
...Registered Nurse (RN) in the Telemetry Unit, where you will provide specialized care to patients requiring... ...comfort. Create personalized care plans in collaboration with interdisciplinary... ...patients and families about cardiac health, treatment plans, and recovery processes...UnitHealth InsuranceWork at office- ...patient population(s)/specific health condition, by the health... ...implements an individualized plan of care, and evaluates the patient... ...Med/Surg; ED Observation/Clinical Decision Units; Clinical Rotations as part... ...of employment. Skills Or Special Abilities Provides care to assigned...UnitHealth InsuranceFull timeTemporary workNight shift
Parkland Health
Dallas, TX3 days ago - ...the support of a dedicated clinical team.Required... ...Registered Nurse provides specialized, family-centered care to mothers... ...newborns in the postpartum unit. This role involves assessing maternal and newborn health, implementing care plans, and supports breastfeeding...UnitHealth InsuranceTemporary work
Fusion Medical Staffing
Dallas, TX3 days ago $156.6k - $266.7k
...PCM! Whether you work in our Home Care, Clinical Research, Impairments, or Catastrophic... ...Contractor position.* The Principal Investigator (PI) is responsible for conducting objective... ...~ Flexible Spending Account (FSA) ~ Health Savings Account (HSA) ~ Paid Time Off...Temporary workFor contractorsWork at officeImmediate startFlexible hoursProfessional Case Management
Dallas, TX3 hours ago- ...seeing patients in the clinic Incentives/Benefits... ...for medical, behavioral health, prescription drugs, dental... ...insurance ~401(k) plan with employer matching... ...Heart Hospital: ~63-bed specialized adult Medical City... ...8-bed progressive care unit with 24/7 intensivist/hospital...UnitHealth InsuranceFull timeMonday to FridayFlexible hours
Do you want to receive more vacancies?
Subscribe and receive similar vacancies to Clinical Special Investigations Unit Investigator- Health Plan. Be the first to apply!
Related searches
- credit investigator Dallas, TX
- case investigator Dallas, TX
- healthcare investigator Dallas, TX
- special investigator Dallas, TX
- federal investigator Dallas, TX
- surveillance investigator Dallas, TX
- employee relations investigator Dallas, TX
- compliance investigator Dallas, TX
- human rights investigator Dallas, TX
- opm background investigator Dallas, TX