Note: The job is a remote job and is open to candidates in USA. TriWest Healthcare Alliance is dedicated to serving America’s heroes by connecting them to healthcare in the community. The Program Integrity Investigator is responsible for identifying, analyzing, and reporting suspected fraud, waste, and abuse cases related to the TRICARE program, while ensuring compliance with federal regulatory requirements.
Responsibilities
- Independently researches FWA issues and effectively employs investigative resources/techniques in achieving projected PI performance goals and outcomes, requiring minimal direction
- Maintains the confidentially and non-discoverability of all fraud and abuse, quality assurance, quality management, and risk management issues
- Reconciles special, unresolved issues associated with beneficiary and provider inquires
- Facilitates and supports Program Integrity goals, objectives, and contract compliance
- Readily accesses and interprets VA, DHA, TRICARE and TriWest guidelines, policies and procedures
- Effectively utilizes appropriate data systems as provided and required by TriWest to identify, research, document and track fraud and abuse issues and activities
- Participates in and/or completes VA, DHA/TRICARE directed leads, audits, investigations, data collection, and medical
- Record reviews for fraud and abuse case development
- Proactively identifies and researches potential fraud and abuse issues
- Performs as a witness in court as requested
- Researches and investigates health care fraud issues, claims data, medical records as they relate to potential fraud and abuse cases (i.e.; problem provider issues)
- Prepares and submits medical records for PI clinical review as appropriate
- Ensures accuracy, completeness, and timely submission of all required leads, reports, audits, and case development activities and documents
- Coordinates/liaises with TriWest departments, PGBA POC’s, and government agencies in researching, determining, and reporting FWA issues
- Participates in and contributes to PI education and training for beneficiaries, providers, subcontractor, and TriWest interdepartmental personnel regarding fraud and abuse
- Assists supervisor in the preparation and compilation of monthly, quarterly, semiannual, and special reports as required
- Participates in system enhancements for reporting fraud and abuse activities
- Facilitates the development of Program Integrity materials for staff, provider and beneficiary education and training as well as assist other departments with educational requests
- Facilitates the development of Program Integrity materials for provider seminars, provider newsletter, and quarterly bulletins
- Assists in the development of quality studies as directed by TriWest Medical Directors
- Assists supervisor with the annual review of PI policies and desk procedures
- Demonstrates effective use of documentation systems for communication, tracking, trending, and reporting purposes
- Research and prepare appropriate and timely responses to beneficiaries, provider and congressional compliant issues referred to Program Integrity by other company departments
- Interfaces with all levels of TriWest employees and maintains effective working relationships while adhering to all customer service goals and guidelines
- Demonstrates flexibility and adaptability towards achieving PI departmental performance/production goals and objectives
- Routinely processes recoupment requests, live claims, and performs other duties as assigned. Attends and participates in continuous training opportunities in current schemes and trends related to FWA
- Participates in and contributes to FWA information-sharing resources, task forces, and joint investigative efforts
- Regular and reliable attendance is required
Skills
- 2 years of experience in fraud, waste and abuse investigations, or equivalent claim auditing experience
- U.S. Citizenship
- Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
- Experience with data analysis techniques, to include Excel and/or SQL expressions
- High School Diploma or GED required
- Experience with quality review standards and healthcare claims analysis techniques
- Knowledge of medical billing regulations and practices, as well as standard healthcare benefits and exclusions
- Knowledge of current trends in healthcare fraud, waste and abuse
- Knowledge of CMS benefits and policies
- Knowledge of Facets
- Certified Coder (CPC, CPC-P, CCA, CCS-P), AHFI, or other related certification
- Experience with IBM's Fraud and Abuse Management System (FAMS) and Case Manager Solutions
- Experience with PeopleSoft and MS Office Suite
Benefits
- Medical, Dental and Vision Coverage
- Paid time off
- 401(k) Retirement Savings Plan (with matching)
- Short-term and long-term disability, basic life, and accidental death and dismemberment insurance
- Tuition reimbursement
- Paid volunteer time
- Frequent pay raises
- Overtime opportunities to earn even more
- Recognition and reward programs
Company Overview
TriWest Healthcare Alliance - Serving Those Who Serve. At TriWest, we honor the sacrifice and service of our nations military families by It was founded in 1996, and is headquartered in Phoenix, Arizona, USA, with a workforce of 1001-5000 employees. Its website is http://triwest.com.