SIU Investigator - 153677

Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:

Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women

Childrens Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR

Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.

Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.

Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.

The SIU Investigator performs reviews of claim lines flagged by Community's SIU and Community's SIU Contractor. The SIU investigator will assist the SIU manager in gathering information from internal and external partners for investigations and audits. The SIU investigator will coordinate with internal and external resources in determining the appropriateness of codes found in administrative and medical claims and develop reports of findings and recommendations for the SIU function.

QUALIFICATIONS:

• Bachelor's degree required, Certification in Coding and Medical Billing, Accredited Health Care Fraud Investigator (AHFI) or Certified Fraud Investigator (CFE) certification required
• 5 years' experience in Healthcare coding in the medical industry directly related to determining appropriate diagnosis, procedure and other codes used in billing for services, utilization management, medical record auditing.

OTHER SKILLS:

• Solid Knowledge of Medicare, Medicaid and commercial coding practices.
• Thorough understanding of Current Procedural Terminology (CPT), Healthcare Common Procedure Coding Systems (HCPCS) and International Classification of Diseases, and Tenth Revision Clinical Modification (ICD-10-CM) standards (or latest version)
• Above Average Verbal (Heavy Public Contact);
• Writing /Composing (Correspondence / Reports)
• Medical Terminology

Community employees benefits are provided by Harris Health. These benefits are designed to provide you with flexibility and choices in meeting your specific needs.

Community is an Equal Opportunity Employer.