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Company

TriWest Healthcare Alliance · 1 day ago

Manager, TRICARE Program Integrity

Phoenix, AZ

Full-time

Remote

Mid, Senior Level

$130K/yr - $130K/yr

5+ years exp

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Health Care

Actively Hiring

No H1B

U.S. Citizen Only

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Responsibilities

Maintains a complete understanding of the contractual requirements for the program integrity function through the review of TRICARE, Medicare, and other Government agency directives and regulations.

Responsible for the day-to-day management of assigned staff to ensure compliance with departmental policies and goals. Will include tracking the status of cases and projects as well as the staff's achievement of productive and qualitative goals and objectives and providing timely periodic feedback to staff on achievements and/or needed improvements.

Assist with development of FWA case development as needed.

Assists PI leadership with engagement with external entities such as Defense Health Agency, Health Care Fraud Division and the DoD Office of Inspector General (OIG) regarding FWA case work.

Develops education and training materials for distribution to beneficiaries and providers.

Contributes to the effective use of artificial intelligence antifraud software for detecting provider fraud, waste, and abuse.

Ensures the accuracy, completeness, and timely preparation of all required internal and external reports, lead requests and case submissions.

Interfaces with TriWest functional areas, and claims processing subcontractors as needed on fraud, waste, and abuse cases.

Demonstrates efficient use of all documentation systems for communication, tracking, trending and reporting purposes.

Interfaces with all levels of TriWest employees and maintains effective working relationships following customer service goals and guidelines.

Demonstrates flexibility and adaptability.

Performs other duties as assigned.

Regular and reliable attendance is required.

Qualification

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Certification in fraud investigationsSupervisory experienceInvestigative experienceClaims processingStatistical analysisTeaching materials preparationVA community care experienceTRICARE experienceMedicare experienceManaged care programs experienceClaim coding certificationICD-9 codingCPT codingDSM codingHCPCS codingRisk management methodologies

Required

Bachelor's degree in healthcare administration, business administration, criminal justice, management or related field from an accredited college or university in a related field; or certification in fraud investigations (Accredited Healthcare Fraud Investigator and/or Certified Fraud Examiner); or equivalent experience

U.S. Citizen

Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation

A minimum of 3 years of supervisory experience

5+ years investigative experience with 2 - 3 years’ experience in detecting, investigating, and preventing fraud, waste and abuse

2 years’ experience in claims processing

Familiarity with statistical analysis processes

Experienced in the preparation and presentation of teaching materials; assessment evaluations and writing skills