[Remote] Program Integrity Investigator (Healthcare Fraud Waste & Abuse)

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.ResponsibilitiesIndependently researches FWA issues and effectively employs investigative resources/techniques in achieving projected PI performance goals and outcomes, requiring minimal directionMaintains the confidentially and non-discoverability of all fraud and abuse, quality assurance, quality management, and risk management issuesReconciles special, unresolved issues associated with beneficiary and provider inquiresFacilitates and supports Program Integrity goals, objectives, and contract complianceReadily accesses and interprets VA, DHA, TRICARE and TriWest guidelines, policies and proceduresEffectively utilizes appropriate data systems as provided and required by TriWest to identify, research, document and track fraud and abuse issues and activitiesParticipates in and/or completes VA, DHA/TRICARE directed leads, audits, investigations, data collection, and medicalRecord reviews for fraud and abuse case developmentProactively identifies and researches potential fraud and abuse issuesPerforms as a witness in court as requestedResearches 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 appropriateEnsures accuracy, completeness, and timely submission of all required leads, reports, audits, and case development activities and documentsCoordinates/liaises with TriWest departments, PGBA POC’s, and government agencies in researching, determining, and reporting FWA issuesParticipates in and contributes to PI education and training for beneficiaries, providers, subcontractor, and TriWest interdepartmental personnel regarding fraud and abuseAssists supervisor in the preparation and compilation of monthly, quarterly, semiannual, and special reports as requiredParticipates in system enhancements for reporting fraud and abuse activitiesFacilitates the development of Program Integrity materials for staff, provider and beneficiary education and training as well as assist other departments with educational requestsFacilitates the development of Program Integrity materials for provider seminars, provider newsletter, and quarterly bulletinsAssists in the development of quality studies as directed by TriWest Medical DirectorsAssists supervisor with the annual review of PI policies and desk proceduresDemonstrates effective use of documentation systems for communication, tracking, trending, and reporting purposesResearch and prepare appropriate and timely responses to beneficiaries, provider and congressional compliant issues referred to Program Integrity by other company departmentsInterfaces with all levels of TriWest employees and maintains effective working relationships while adhering to all customer service goals and guidelinesDemonstrates flexibility and adaptability towards achieving PI departmental performance/production goals and objectivesRoutinely 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 FWAParticipates in and contributes to FWA information-sharing resources, task forces, and joint investigative effortsRegular and reliable attendance is requiredSkills2 years of experience in fraud, waste and abuse investigations, or equivalent claim auditing experienceU.S. CitizenshipMust be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigationExperience with data analysis techniques, to include Excel and/or SQL expressionsHigh School Diploma or GED requiredExperience with quality review standards and healthcare claims analysis techniquesKnowledge of medical billing regulations and practices, as well as standard healthcare benefits and exclusionsKnowledge of current trends in healthcare fraud, waste and abuseKnowledge of CMS benefits and policiesKnowledge of FacetsCertified Coder (CPC, CPC-P, CCA, CCS-P), AHFI, or other related certificationExperience with IBM's Fraud and Abuse Management System (FAMS) and Case Manager SolutionsExperience with PeopleSoft and MS Office SuiteBenefitsMedical, Dental and Vision CoveragePaid time off401(k) Retirement Savings Plan (with matching)Short-term and long-term disability, basic life, and accidental death and dismemberment insuranceTuition reimbursementPaid volunteer timeFrequent pay raisesOvertime opportunities to earn even moreRecognition and reward programsCompany OverviewTriWest 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.