Job Description

Are you looking for a career that offers both purpose and the opportunity for growth? Parkland Community Health Plan (PCHP) is a proud member of the Parkland Health family. PCHP is a Medicaid Managed Care Organization servicing Texas Medicaid and CHIP in the Dallas Service Area. PCHP works to fulfill of our mission by empowering members to live healthier lives. By joining PCHP, you become part of a team focused on innovation, person-centered care, and fostering stronger communities. As we continue to expand our services, we offer opportunities for you to grow in your career while making a meaningful impact. Join us and work alongside a talented team where healthcare is more than just a job—it’s a passion to serve and improve lives every day.

Primary Purpose

Responsible for implementing an effective compliance program that includes prevention, investigation and pursuit of fraud, waste, and abuse violations. Accountable for compliance by overseeing, follow-up and resolution of investigations in partnership with state and federal programs.

Minimum Specifications

Education

· Bachelor’s degree in business administration or related discipline is required.

Experience

· Five years of Fraud, Waste, and Abuse investigative experience in Manage Care or government/contractor oversight setting of a government program; AND/OR

· Two years of Fraud, Waste, and Abuse investigative experience in Manage Care or government/contractor oversight setting of a government program AND Three years of experience in claims auditing, revenue management, medical records auditing, data analysis, medical coding, or medical compliance auditor.

Equivalent Education and/or Experience

· May have the equivalent combination of education and/or experience in lieu of education.

· Seven years of Fraud, Waste, and Abuse investigative experience in Manage Care or government/contractor oversight setting of a government program; OR

· Five years of Fraud, Waste, and Abuse investigative experience in Mange Care or government/contractor oversight setting of a government program AND Two years of experience in claims auditing, revenue management, medical records auditing, data analysis, medical coding, or medical compliance auditor; OR

· Two years of Fraud, Waste, and Abuse investigative experience in Mange Care or government/contractor oversight setting of a government program AND Five years of experience in claims auditing, revenue management, medical records auditing, data analysis, medical coding, or medical compliance auditor.

Certification/Registration/Licensure

· Must be currently certified and in good standing or obtain certification within eighteen (18) 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).

· Must be current Certified Professional Coder (CPC) and/or any other certified medical certification holder by American Academy of Professional Coders IF medical coding experience is being utilized to meet the experience mix requirement.

· Required Tests for Placement

Skills or Special Abilities

· Excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines. Ability to communicate complex information in understandable terms.

· Strong interpersonal and conflict resolution skills with the ability to establish and maintain effective working relationships across and beyond the organization.

· Excellent analytical and problem-solving skills.

· Strong time management and organizational skills with the ability to manage multiple demands and respond to rapidly changing priorities.

· Ability to write clearly and succinctly with a high level of attention to detail.

· Proficient computer and Microsoft Office skills. Ability to learn new software programs.

· Knowledge of Texas Medicaid, National Committee for Quality Assurance (NCQA), the Uniformed Managed Care Contract, and the Uniform Managed Care Manual.

Responsibilities

Research and Analysis

· Responsible for referral intake process and developing leads presented to the SIU to assess and determine whether potential fraud, waste, or abuse is corroborated by evidence.

· Conducts preliminary investigations, along with witness interviews, within the mandated period of time required by either state and/or federal contracts and/or regulations.

· Conducts non-medical/non-coding related extensive investigations and makes determinations as to whether the investigation and/or audit identified potential fraud, waste, or abuse.

· Prepares detailed preliminary and extensive investigation referrals to state and/or federal regulatory and/or law enforcement agencies when potential fraud, waste, or abuse is identified as required by regulatory and/or contract requirements.

· Interacts with regulatory and/or law enforcement agencies regarding case investigations.

· Conducts detailed claims analysis and prepares audit results letters to providers when overpayments are identified.

· Conducts root cause analysis and communicating systems, policy or other control gaps identified to operating and/or audit management as well as Medicaid Compliance, where appropriate.

· Contributes to educational fraud awareness training efforts for PCHP employees and others to deter and minimize health care fraud losses.

· 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.

Quality

· Integrate health literacy principles into all communication including Members and Providers.

· Support strategies that meet clinical, quality and network improvement goals.

· Promotes the use of Health Information Technology to support and monitor the effectiveness of health and social interventions and make data-driven recommendations as needed.

· For staff in clinical roles, foster collaborative relationships with members and/or providers to promote and support evidence-based practices and care coordination.

Regulatory

· Ensures work is carried out in compliance with regulatory and/or accreditation standards as well as contractual requirements.

Professional Accountability

· Promotes and supports a culturally welcoming and inclusive work environment.

· Acts with the highest integrity and ethical standards while adhering to Parkland's Mission, Vision, and Values.

· Adheres to organizational policies, procedures, and guidelines.

· Completes assigned training, self-appraisal, and annual health requirements timely.

· Adheres to hybrid work schedule requirements.

· Attends required meetings and town halls.

· Recognizes and communicates ethical and legal concerns through the established channels of communication.

· Demonstrates accountability and responsibility by independently completing work, including projects and assignments on time, and providing timely responses to requests for information.

· Maintains confidentiality at all times.

· Performs other work as requested that is reasonably related to the employee’s position, qualifications, and competencies.

Job Accountabilities

· Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of PCHP.

· Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.

· Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding.

Parkland Community Health Plan (PCHP) prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status. 

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