Responsible for supporting the prevention, detection, investigation, reporting, and when appropriate, recovery of money related to Texas Medicaid fraud, waste, and abuse within Cook Children's Health Plan's provider network, members, and staff. Duties include generating accurate and timely analysis and reports to support the SIU preliminary investigation and medical record audit to identify fraud, waste, and abuse.The position may also work with other internal departments, including Compliance, Corporate Legal Counsel, and the health plan Medical Director for additional oversight and compliance with Texas Medicaid Fraud, Waste and Abuse regulatory requirements. Responsibilities include importing, transforming, and validating data from the SIU team for decision-making purposes on identifying provider fraud or provider education.
Bachelor's Degree Preferred.
3 years claim auditing experience.
Extensive knowledge of claims processing with advanced knowledge of medical benefit, medical terminology and coding.
Proficient in ICD-9/ICD-10 and CPT coding.
Knowledge of governmental programs (Medicaid & CHIP).
One year experience conducting data analyses and reporting.
Must have Microsoft Office Skills with Word, Excel and Access.
CPC or CCS Coding Certification Preferred.
Internal Number: 45689
About Cook Children's Health Care System
Cook Children's Health Care System is a not-for-profit, nationally recognized pediatric health care organization comprised of eight entities – a Medical Center, Physician Network, Home Health company, Northeast Hospital, Pediatric Surgery Center, Health Plan, Health Services Inc., and Health Foundation.Cook Children's Medical Center Based in Fort Worth, Texas, the integrated system has more than 60 primary and specialty care offices throughout North Texas. Its service region includes Denton, Hood, Johnson, Parker, Tarrant and Wise counties, with an additional referral area encompassing nearly half the state.Cook Children's traces its roots back to 1918, but throughout its continual change and robust growth, it still embraces an inspiring promise – to improve the health of every child in its region through the prevention and treatment of illness, disease and injury. To live up to this promise, Cook Children's combines the art of caring with the use of leading technology and extraordinary collaboration to provide exceptional care for every child, every day.History – Cook Children's has a rich history of nearly a century of caring for children.Our Promise – Knowing that every child's ...life is sacred, it is the promise of Cook Children's to improve the health of every child in our region through the prevention and treatment of illness, disease and injury.Companies – Based in Fort Worth, Texas, Cook Children's is a not-for-profit organization that is comprised of eight nationally recognized companies.Community Health Outreach – Cook Children's Community Health Outreach works together with over 150 partner organizations to improve the safety and health of at-risk children through education, disease and injury prevention and support.Clinical Research – Cook Children's is home to a skilled team of research-minded physicians, nurses and health care professionals and administrators who drive our commitment to excellent clinical care and the search for medical advances.Public Relations – Cook Children's Public Relations works with national and local media outlets, produces Cook Children's publications, coordinates special events and helps develop key relationships within the community.Contractor & Vendor Information – Cook Children's contractors and vendors must ensure their employees are knowledgeable about working with our organization.Sponsorship guidelines – Cook Children's sponsors a select number of events that are strongly aligned with its promise to improve the health of every child in the region through the prevention and treatment of illness, disease and injury.