Supervisor of Program Integrity

4 days ago

Phoenix, Arizona, United States Triwest Healthcare Full time
Job Summary

We are seeking a highly skilled and experienced Supervisor, Program Integrity to join our team at TriWest Healthcare Alliance. As a key member of our Program Integrity team, you will be responsible for supervising and assisting in the identification, analysis, and case development of suspected fraud and abuse in the Department of Veterans Affairs (VA), Healthcare Finance Administration (HCFA), and the Department of Defense, Defense Health Agency for the TRICARE program.

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.
  • 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.
Requirements
  • 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 year's 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 Qualifications
  • 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).
Working Conditions

Availability to work any shift. Works in a remote office environment, with minimal travel. Extensive computer work with prolonged sitting.

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