Program Integrity Investigator (Healthcare Fraud Waste & Abuse)

TriWest Healthcare Alliance; Phoenix (AZ); On-site; USD 50,000 - 70,000; Full time

Job summary

A healthcare organization is seeking a PI Investigator responsible for investigating fraud, waste, and abuse. This role requires 2 years of relevant experience and can be performed remotely in several U.S. states. The ideal candidate will have a background in healthcare claims analysis, data analysis techniques, and knowledge of billing regulations. Responsibilities include researching and documenting FWA issues, ensuring compliance with federal guidelines, and supporting the Program Integrity objectives.

Qualifications

• 2 years of experience in fraud, waste and abuse investigations or equivalent claim auditing experience.
• Able to receive a favorable Interim and adjudicated final Department of Defense background investigation.
• Experience with quality review standards and healthcare claims analysis techniques.

Responsibilities

• Research FWA issues effectively utilizing investigative resources.
• Maintain confidentiality and non-discoverability of fraud and abuse issues.
• Support Program Integrity goals and contract compliance.

Skills

Data analysis techniques (Excel/SQL)

Fraud, waste, abuse investigations

Knowledge of medical billing regulations

Education

High School Diploma or GED

Tools

IBM's Fraud and Abuse Management System (FAMS)

PeopleSoft

MS Office Suite

Job description

Profile

We offer remote work opportunities (AK, AR, AZ, CO, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, WA, WI & WY only). Our Department of Defense contract requires U.S. citizenship and a favorably adjudicated DOD background investigation for this position. Veterans, Reservists, Guardsmen and military family members are encouraged to apply!

Job Summary

This position is under the general guidance of the Director, Program Integrity and reports directly to the Supervisor, Program Integrity. The PI Investigator is responsible for the identification, analysis, case development, and reporting of suspected fraud, waste and abuse (FWA) cases as defined by the Department of Veterans Affairs (VA), the Healthcare Finance Administration (HCFA) and the Department of Defense, Defense Health Agency for the TRICARE program; requests and reviews issue‑related medical claims and records for FWA and/or administrative and clerical error(s). It complies with the Veterans Affairs Community Care Network (CCN) and TRICARE T‑5 contracts; DHA and TRICARE program guidelines and pertinent Federal regulatory requirements; assists supervisors with FWA trending and reporting requirements; coordinates and assists with investigations and prosecutions by federal agencies; interfaces directly with Veterans, Military members and family (as warranted), providers, subcontractors, and other TriWest departments on FWA issues; assists supervisor with the education and training of TriWest, subcontractor, and provider personnel on current FWA matters; prepares appropriate responses to provider compliance issues and complaints referred to Program Integrity by other TriWest departments or external referrals.

Education & Experience

Required

• 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, including 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

Preferred

• 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

Key Responsibilities

• Independently researches FWA issues and effectively employs investigative resources/techniques to achieve projected PI performance goals and outcomes, requiring minimal direction.
• Maintains the confidentiality 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 inquiries.
• 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.