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.
Veteran, Military Spouse or Military Affiliated are encouraged to apply!
Job Summary
Under the direction of the Director, Program Integrity, assists in the identification, analysis, case development and reports of any suspected fraud and/or abuse as defined by TRICARE. Reviews medical records for fraud and abuse issues. Complies with Program Integrity requirements within the TRICARE West Region; assists with trending and reporting requirements; and interfaces with TRICARE beneficiaries, providers and subcontractors on fraud and abuse issues. Assists with the update of education and training. Assists with the update of policy and procedure protocols for the Program Integrity unit.
Education & Experience
- Registered Nurse or Physician’s Assistant with at least five years varied clinical experience in a managed care setting
- Education or experience to perform anti-fraud and abuse pre-payment and post-payment reviews
- 3 years utilization review, quality management, or case management experience
- Must be a U.S. Citizen
- Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
- Experience in the preparation and presentation of teaching materials; assessment evaluations, and writing skills
- Certified Coder (CPC, CPC-P, CCA, CCS-P), AHFI, CFE, or other related certification
Key Responsibilities
- Resource clinician for Program Integrity staff.
- Research and investigate medical issues as they relate to potential fraud and abuse cases, to include perform anti-fraud and abuse pre-payment reviews or post-payment reviews.
- Conducts medical records and claims reviews for potential fraud and abuse issues, as well as medical necessity, benefit coverage, utilization and quality of care issues and outcomes.
- Coordinate and compile written Investigative Summary Reports in conjunction with PI investigators upon completion of records review.
- Maintains the confidentiality and non-discoverability of all fraud and abuse, quality assurance, quality management and risk management issues.
- Facilitate and support the Program Integrity Goals and Objectives.
- Readily accesses and interprets TRICARE and Medicare coverage guidelines, policies and procedures as well as TriWest policies and procedures.
- Effective utilization of the antifraud artificial intelligence software.
- Effective utilization of all documentation systems related to fraud and abuse activities and reporting systems.
- Participates in DHA directed investigation, data collection and medical record reviews for fraud and abuse case development.
- Performs as a witness in court as requested.
- Prepares and submits medical records for peer review as appropriate.
- Ensures accuracy, completeness and timely submission of all required reports, review audits, case development activities and documents.
- Collaborates with all government agencies as directed to support the fraud and abuse efforts.
- Participates and contributes to program integrity education and training for beneficiaries, providers, subcontractor and TriWest staff regarding fraud and abuse.
- Participates in system enhancements for reporting fraud and abuse activities.
- Participates in the annual review of Program Integrity policies, procedures and desk procedures.
- Demonstrates effective use of documentation systems for communication, tracking, trending and reporting purposes.
- Establishes and maintains effective working relationships with all levels of TriWest employees, government and subcontractor staff.
- Demonstrates flexibility and adaptability.
- Other duties as assigned.
- Regular and reliable attendance is required.
Competencies
Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.
Computer Literacy: Ability to manage large amounts of complex information easily, communicate clearly, and draw sound conclusions.
Delegation Skills: Provide clear performance expectations for projects and ensure adequate access to resources for completion.
High Intensity Environment: Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.
Multi-Tasking / Time Management: Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environment.
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.
Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment.
Technical Skills: Knowledge of TRICARE policies and procedures, knowledge of Case Management, Utilization Management, and Quality Management practices and principles, and knowledge of Managed Care concepts, alternative care treatments, and community resources. Proficient with Current Procedural Terminology coding.
Working Conditions
- Availability to cover any work shift
- Department of Defense security clearance required
- Repetitive data entry with telephone headset and long periods of 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.
DoD Statement
Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.
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 $90,000 to $95,000 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.