Remote Program Integrity & FWA 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

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