Program Integrity Investigator

TriWest Healthcare Alliance; Phoenix (AZ); On-site; USD 66,000 - 73,000; Full time

Benefits offered by this job

Medical, Dental and Vision Coverage

Paid time off

401(k) Retirement Savings Plan

Disability insurance

Tuition reimbursement

Paid volunteer time

Job summary

TriWest Healthcare Alliance in Phoenix, AZ is seeking a PI Investigator to identify, analyze, and report suspected fraud, waste and abuse (FWA) within the TRICARE program under DoD contracts. You will review medical claims, coordinate with federal agencies, and support education of TriWest staff on FWA matters.

Role requires attention to detail, data analysis skills, and the ability to work with providers, beneficiaries, and internal teams while maintaining confidentiality and compliance with

Qualifications

• 2 years of fraud, waste and abuse investigations or equivalent claims auditing.
• U.S. Citizenship.
• Must obtain favorable DoD background investigation.
• Experience with data analysis techniques using Excel/SQL.
• High School Diploma or GED.
• Experience with healthcare claims analysis and regulatory practices.
• Knowledge of medical billing regulations and standard benefits.

Responsibilities

• Independently researches FWA issues and uses investigative resources to meet performance goals.
• Maintains confidentiality of fraud and abuse information and compliance data.
• Reconciles unresolved beneficiary and provider inquiries.
• Facilitates PI goals, contract compliance, and reporting.
• Interprets VA, DHA, TRICARE and TriWest guidelines for investigations.
• Uses TriWest data systems to identify, document, and track FWA issues.

Skills

Fraud investigations

Data analysis

U.S. Citizenship

Background investigation readiness

Healthcare claims analysis

Excel / SQL

FWA knowledge

CMS benefits knowledge

Facets familiarity

Certifications (CPC/CCS-P)

PeopleSoft / MS Office

Education

High School Diploma or GED

Tools

Excel

SQL

FAMS

Case Manager Solutions

TRICARE data systems

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 US 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 t 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). 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; assist 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, 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

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 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.
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• 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.

Competencies

Commitment to Task: Ability to conform to established policies and procedures; exhibit high motivation.

Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.

Coping / Flexibility: Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required.

Independent Thinking / Self-Initiative: Critical thinkers with ability to focus on things which matter most to achieving outcomes; commitment to task to produce outcomes without direction and to find necessary resources.

Information Management: Ability to manage large amounts of complex information easily, communicate clearly, and draw sound conclusions.

Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.

Problem Solving / Analysis: Ability to solve problems through systematic analysis of processes with sound judgment; has a realistic understanding of relevant issues.

Technical Skills: Knowledge with CPT4, ICD-10-CM, HCPCS, DRG and Revenue Code coding conventions. Knowledge of standard benefit coverage policies and exclusions, including National and Local Coverage Determinations. Knowledge of standard healthcare billing regulations and practices.

Working Conditions

• Availability to work any shift
• Works in a standard office environment, with minimal travel
• Extensive computer work with prolonged sitting

Company Overview

Taking Care of Our Nation’s Heroes.

It’s Who We Are. It’s What We Do.

Do you have a passion for serving those who served?

Join the TriWest Healthcare Alliance Team! We’re On a Mission to Serve

Our job is to make sure that America’s heroes get connected to health care in the community.

At TriWest Healthcare Alliance, we’ve proudly been on that important mission since 1996.

Benefits

We’re more than just a health care company. We’re passionate about serving others! We believe in rewarding loyal, hard-working people who are willing to learn as they grow. TriWest Healthcare Alliance values teamwork. Join our team, fulfill your responsibilities, and you may also be considered for frequent pay raises, overtime opportunities to earn even more, recognition and reward programs, and much more. Of course, we also offer a comprehensive and progressive compensation and benefits package that includes:

• 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

TriWest job postings typically include a salary range, which can vary based on the specific role and location, but generally this position ranges from around $66,000 to $73,000 per year.

Equal Employment Opportunity

TriWest Healthcare Alliance is an equal employment opportunity employer. We are proud to have an inclusive work environment and know that a diverse team is a strength that will drive our success. To that end, TriWest strives to create an inclusive environment that supports diversity at every organizational level, and we highly encourage candidates from all backgrounds to apply. Applicants are considered for positions based on merit and without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability or any other consideration made unlawful by applicable federal, state, or local laws.