Program Integrity Clinical Specialist; RN or PA Req'd

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

Join to apply for the Program Integrity Clinical Specialist (RN or PA Req'd) role at Tri West Healthcare Alliance.

Remote work opportunities available in 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. Veteran, Military Spouse or Military Affiliated are encouraged to apply!

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, and with the update of policy and procedure protocols for the Program Integrity unit.

• Registered Nurse or Physician’s Assistant with at least five years varied clinical experience in a managed care setting
• Education or experience to perform anti‑fraud and abuse pre‑payment and post‑payment reviews
• 3 years utilization review, quality management, or case management experience
• Must be a U.S. Citizen
• Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation

• Experience in the preparation and presentation of teaching materials; assessment evaluations, and writing skills
• Certified Coder (CPC, CPC‑P, CCA, CCS‑P), AHFI, CFE, or other related certification

• Resource clinician for Program Integrity staff.
• Research and investigate medical issues as they relate to potential fraud and abuse cases, including performing anti‑fraud and abuse pre‑payment reviews or post‑payment reviews.
• Conduct 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.
• Maintain 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 access and interpret TRICARE and Medicare coverage guidelines, policies and procedures as well as Tri West policies and procedures.
• Effectively utilize the antifraud artificial intelligence software.
• Effectively utilize all documentation systems related to fraud and abuse activities and reporting systems.
• Participate in DHA directed investigation, data collection and medical record reviews for fraud and abuse case development.
• Perform as a witness in court as requested.
• Prepare and submit medical records for peer review as appropriate.
• Ensure accuracy, completeness and timely submission of all required reports, review audits, case development activities and documents.
• Collaborate with all government agencies as directed to support the fraud and abuse efforts.
• Participate and contribute to program integrity education and training for beneficiaries, providers, subcontractors and Tri West staff regarding fraud and abuse.
• Participate in system enhancements for reporting fraud and abuse activities.
• Participate in the annual review of Program Integrity policies, procedures and desk procedures.
• Demonstrate effective use of documentation systems for communication, tracking, trending and reporting purposes.
• Establish and maintain effective working relationships with all levels of Tri West employees, government and subcontractor staff.
• Demonstrate flexibility and adaptability.
• Other duties as assigned.
• Regular and reliable attendance is required.

Communication / People

Skills:

Ability to influence or persuade others under positive or negative circumstances; adapt to different…