Program Integrity Clinical Specialist (RN or PA Req'd)

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.

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. Veteran, Military Spouse or Military Affiliated are encouraged to apply! Job Summary: Under the direction of the Director, Program Integrity, assists in the identification, analysis, case development and reports of any suspected fraud and/or abuse as defined by TRICARE. Reviews medical records for fraud and abuse issues. Complies with Program Integrity requirements within the TRICARE West Region; assists with trending and reporting requirements; and interfaces with TRICARE beneficiaries, providers and subcontractors on fraud and abuse issues. Assists with the update of education and training. Assists with the update of policy and procedure protocols for the Program Integrity unit.

Resource clinician for Program Integrity staff. Research and investigate medical issues as they relate to potential fraud and abuse cases, to include perform anti-fraud and abuse pre-payment reviews or post-payment reviews. Conducts medical records and claims reviews for potential fraud and abuse issues, as well as medical necessity, benefit coverage, utilization and quality of care issues and outcomes. Coordinate and compile written Investigative Summary Reports in conjunction with PI investigators upon completion of records review. Maintains the confidentiality and non-discoverability of all fraud and abuse, quality assurance, quality management and risk management issues. Facilitate and support the Program Integrity Goals and Objectives. Readily accesses and interprets TRICARE and Medicare coverage guidelines, policies and procedures as well as TriWest policies and procedures. Effective utilization of the antifraud artificial intelligence software. Effective utilization of all documentation systems related to fraud and abuse activities and reporting systems. Participates in DHA directed investigation, data collection and medical record reviews for fraud and abuse case development. Performs as a witness in court as requested. Prepares and submits medical records for peer review as appropriate. Ensures accuracy, completeness and timely submission of all required reports, review audits, case development activities and documents. Collaborates with all government agencies as directed to support the fraud and abuse efforts. Participates and contributes to program integrity education and training for beneficiaries, providers, subcontractor and TriWest staff regarding fraud and abuse. Participates in system enhancements for reporting fraud and abuse activities. Participates in the annual review of Program Integrity policies, procedures and desk procedures. Demonstrates effective use of documentation systems for communication, tracking, trending and reporting purposes. Establishes and maintains effective working relationships with all levels of TriWest employees, government and subcontractor staff. Demonstrates flexibility and adaptability. Other duties as assigned. Regular and reliable attendance is required.