TriWest Healthcare Alliance

Program Integrity Specialist (Healthcare Fraud Waste & Abuse)

Recruiting Location Phoenix, AZ
ID 2020-3165

Overview

Taking Care of Our Nation’s Veterans.

 

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.

 

Are you our next Program Integrity Specialist?  

 

This position is under the general guidance of the Director, Corporate Compliance and reports directly to the Supervisor, PI Specialist.  The PI Specialist 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) and the Healthcare Finance Administration (HCFA); requests and reviews issue-related medical claims and records for FWA and/or administrative and clerical error(s).  Complies with the Veterans Affairs Patient-Centered Community Care (PC3) and Veterans Choice Program (VCP) contracts 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, 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.

Responsibilities

TriWest Program Integrity Specialist: 

 

  • 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 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 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, Wisconsin Physicians Service (WS) 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.

Qualifications

Are you qualified? 

 

Required

  • 2 years’ experience in fraud, waste and abuse investigations, or equivalent claim auditing experience
  • 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 or 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

More about working at TriWest Healthcare Alliance

 

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
  • Generous paid time off
  • 401(k) Retirement Savings Plan (with matching)
  • Short-term and long-term disability, basic life, and accidental death and dismemberment insurance

Equal Opportunity Employer

 

TriWest Healthcare Alliance is an equal employment opportunity employer. All qualified applicants are considered for employment, without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other characteristic made unlawful by applicable federal, state, or local laws.

 

Are you ready to make a difference in the lives of our nation’s heroes?

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