Profile
We offer remote work opportunities (AK, AR, AZ, CA, *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 Manager, Program Integrity. The Supervisor, Program Integrity primary responsibilities are to supervise and assist in the identification, analysis, case development and reports of any suspected fraud and/or abuse 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; supervise and assist with trending and reporting requirements; and interface with other VA contractors, Veterans, DHA, Active Duty military members and family, and TriWest Healthcare Alliance providers and subcontractors on fraud and abuse issues.
In addition, supervise and assist with healthcare related studies as directed, assist with the update of education, training and participate in the update of policy and procedure protocols for the Program Integrity Unit; responsible for the assignment and timely completion of all VA and TRICARE, assigned investigative leads and special projects; responsible for all department generated beneficiary and provider recoupment; supervise the research and preparation of appropriate responses to beneficiary and provider compliant issues referred to Program Integrity by other company departments.
Education & Experience
Required:
- Associate Degree or work equivalent
- U.S. Citizenship
- Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation.
- 2+ years’ experience with fraud and abuse reviews or claims analysis techniques
- 1 years’ experience in claims processing
- Supervision or leadership experience
- Knowledge of CMS benefits and policies
- Experience with data analysis techniques, to include Excel and/or SQL expressions
Preferred
- Bachelor's degree in healthcare administration, business administration, criminal justice, management or related field from an accredited college or university in a related field.
- 2 years’ experience in claims processing or quality assurance capacity
- 2+ years experience with healthcare fraud and abuse investigations and techniques
- Certification in fraud investigations (Accredited Healthcare Fraud Investigator and/or Certified Fraud Examiner).
Key Responsibilities
- Supervise and assist with fraud and abuse case development and maintenance through to case closure or submission.
- Supervise and assist on focused reports used in analysis of potential and confirmed fraud and abuse issues.
- Proactively identify and research potential fraud and abuse issues through review of claims data and medical records and other available resources.
- Supervise and assist with gathering of documents and investigation notes requested by subpoena, or OIG/DHA requests.
- Establish productive and qualitative goals and objectives for direct reports and provide timely periodic feedback on needed improvements and/or achievements.
- Maintain the confidentiality and non-discoverability of all fraud and abuse, quality assurance and risk management issues.
- Readily assess and interpret VA/TRICARE coverage guidelines, policies and procedures as well as TriWest policies and procedures.
- Utilize appropriate data systems as provided and required by TriWest to research, document and track fraud and abuse issues and activities.
- Assist in preparation of all reporting requirements established by VA/TRICARE and TriWest monthly, quarterly, semi-annually and special reports as required.
- Participate with all systems enhancements for reporting department activities.
- Facilitate the development of Program Integrity materials for staff, provider and beneficiary education and training as well as assist other departments with educational requests.
- Demonstrate efficient use of all documentation systems for communication, tracking, trending and reporting purposes.
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- Interface with all levels of TriWest employees and maintain effective working relationships.
- Demonstrate flexibility and adaptability.
- Participate in meetings and projects as assigned.
- Perform other duties as assigned.
- Regular and reliable attendance is required.
Competencies
Coaching / Training / Mentoring: Actively foster actions required for desired business outcomes through ongoing constructive feedback.
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.
Information Management: Ability to manage large amounts of complex information easily, communicate clearly, and draw sound conclusions.
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 ICD-9, DSM, CPT and HCPCS coding systems. Knowledge of clinical standards of care and practice. Knowledge of scopes of practice for varied clinical specialties. Ability to determine medical necessity and appropriateness of health care. Thorough knowledge of standard medical treatments and generic quality screens.
Working Conditions
Working Conditions
- Availability to work any shift
- Works in a remote office environment, with minimal travel
- Extensive computer work with prolonged 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
- 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
- Tuition reimbursement
- Paid volunteer time
*Annual base salary for Colorado, Hawaii, Washington D.C. and Washington State residents: $82,000- $104,000 depending on experience*
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 cultivates and supports diversity at every organizational level, including hiring and retaining a diverse workforce, and we highly encourages candidates from all backgrounds to apply. Applicants are considered for positions 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.
