Program Integrity Investigator; Healthcare Fraud Waste & Abuse

Profile

We offer remote work opportunities (AK, AR, AZ, CO, FL, HI, IA, , 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 U.S. citizenship and a favorably adjudicated DOD background investigation for this position. Veterans, Reservists, Guardsmen and military family members are encouraged to apply!

This position is under the general guidance of the Director, Program Integrity and reports directly to the Supervisor, Program Integrity. The PI Investigator 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). It 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 Tri West departments on FWA issues;

assists supervisor with the education and training of Tri West, subcontractor, and provider personnel on current FWA matters; prepares appropriate responses to provider compliance issues and complaints referred to Program Integrity by other Tri West departments or external referrals.

• 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, including 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

• 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 People Soft and MS Office Suite

• Independently researches FWA issues and effectively employs investigative resources/techniques to achieve projected PI performance goals and outcomes, requiring minimal direction.
• Maintains the confidentiality 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 inquiries.
• Facilitates and supports Program Integrity goals, objectives, and contract compliance.
• Readily accesses and interprets VA, DHA, TRICARE and Tri West guidelines, policies and procedures.
• Effectively utilizes appropriate data systems as provided and required by Tri West to identify, research, document and track fraud and abuse issues and activities.