Program Integrity Investigator (Healthcare Fraud Waste & Abuse)

About the role

This position is under the general guidance of the Director, Program Integrity and reports directly to the Supervisor, Program Integrity.

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.
• Captures and tracks fraud and abuse issues and activities using appropriate systems.
• 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.
• Affords assistance to 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.
• 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.

Qualifications

• 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.
• Veterans, Reservists, Guardsmen and military family members are encouraged to apply!

Skills

• Knowledge of medical billing regulations and practices, as well as standard healthcare benefits and exclusions.
• Knowledge of current trends in healthcare fraud, waste and abuse.
• Knowledge of CMS benefits and policies.
• Experience with IBM’s Fraud and Abuse Management System (FAMS) and Case Manager Solutions.
• Experience with PeopleSoft and MS Office Suite.

Benefits

TriWest Healthcare Alliance offers 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.

Pay

$64,000 to $68,000 per year.

Schedule

Availability to work any shift.