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.
- 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
Working Conditions:
- Availability to work any shift
- Works in a standard office environment, with minimal travel
- Extensive computer work with prolonged sitting
