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Community First Health Plans, Inc. (Community First) is an HMO providing health care services to Medicaid and CHIP, Medicare, Marketplace, and Commercial recipients. Community First must ensure that all operations are aligned with the regulatory requirements of the Texas Health and Human Services Commission (HHSC), the Texas Department of Insurance (TDI), the Centers for Medicare and Medicaid Services (CMS), and the National Association of Insurance Commissioners (NAIC).
Job Responsibility:
Leads the organization’s efforts to prevent, detect, investigate, and remediate fraud, waste, and abuse (FWA) across all product lines
Ensures program integrity by setting organizational standards, strengthening internal controls, and overseeing the Special Investigations Unit (SIU) operations, payment integrity analytics, and vendor oversight
Ensures program integrity by setting enterprise standards, strengthening internal controls, and overseeing SIU operations, payment integrity analytics, vendor oversight, and internal auditing functions
Requirements:
Bachelor’s degree is required in accounting, business administration or related field
Experience in interpretation of regulatory agency policies is preferred
Experience with anti-fraud detection and prevention is required
Three years of supervisory experience is preferred
Experience with SEC SOX and/or NAIC MAR audits, and Enterprise Risk Management (ERM) is highly desirable
At least three years of professional audit experience is required
Nice to have:
Experience in interpretation of regulatory agency policies
Three years of supervisory experience
Experience with SEC SOX and/or NAIC MAR audits, and Enterprise Risk Management (ERM)