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 and 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 and 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, do ument 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. 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-orient