Manager, TRICARE Program Integrity at TriWest Healthcare Alliance in Phoenix, Arizona

Job Description:

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 & 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

Under the general direction of the Director, Program Integrity, the Manager, Program Integrity provides guidance, supervision and assistance to Program Integrity staff members in performing professional level work in detecting, investigating and preventing TRICARE beneficiary and provider fraud, waste and abuse of the TRICARE program. The incumbent will ensure that TriWest's Program Integrity function addresses the TRICARE Program goals and objectives for detecting and preventing beneficiary and provider fraud, waste and abuse. The Manager will be an integral part of directing staff on the use of artificial Intelligence Software in detecting, reporting and preventing fraud and abuse. The incumbent is responsible for maintaining confidentiality and non-discoverability of fraud, waste, and abuse cases developed and/or handled by TriWest's program integrity function.

Education & Experience

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

Preferred:

• Master's degree in healthcare administration, business administration, criminal justice, management or related field
• Experience in VA community care, TRICARE, Medicare, and/or managed care programs
• Certification in claim coding

Key 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.

Competencies

Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.

Creativity / Innovation: Ability to develop unique and novel solutions to problems; view change as necessary.

Independent Thinking / Self-Initiative: Critical thinkers with ability to focus on things which matter most to achieving outcomes; commitment to task to produce outcomes without direction and to find necessary resources.

Information Management: Ability to manage large amounts of complex information easily, communicate clearly, and draw sound conclusions.

Leadership: Successfully manage different styles of employees; provide clear direction and effective coaching.

Multi-Tasking / Time Management: Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environment.

Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment.

Technical Skills: Working knowledge of ICD-9, CPT, DSM, and HCPCS coding systems; thorough knowledge of standard medical treatments and quality indicators; knowledge of claims processing, utilization review, case management, quality assurance, and risk management methodologies.

Working Conditions

Working Conditions:

• Availability to work non-regular hours as necessary
• Works within a standard office environment, with minimal travel
• Extensive computer work with prolonged sitting

Company Overview

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.

DoD Statement

Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.

Benefits

We're more than just a health care company. We're passionate about serving others! We believe in rewarding loyal, hard-working people who are willing to learn as they grow. TriWest Healthcare Alliance values teamwork. Join our team, fulfill your responsibilities, and you may also be considered for frequent pay raises, overtime opportunities to earn even more, recognition and reward programs, and much more. Of course, we also offer a comprehensive and progressive compensation and benefits package that includes:

• Medical, Dental and Vision Coverage


• Generous paid time off


• 401(k) Retirement Savings Plan (with matching)


• Short-term and long-term disability, basic life, and accidental death and dismemberment insurance


• Tuition reimbursement


• Paid volunteer time

*Annual base salary for Colorado, Hawaii, Washington D.C. and Washington State residents: Approx. $130,000 depending on experience*

Equal Employment Opportunity

TriWest Healthcare Alliance is an equal employment opportunity employer. We are proud to have an inclusive work environment and know that a diverse team is a strength that will drive our success. To that end, TriWest strives to create an inclusive environment that cultivates and supports diversity at every organizational level, including hiring and retaining a diverse workforce, and we highly encourages candidates from all backgrounds to apply. Applicants are considered for positions without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability or any other consideration made unlawful by applicable federal, state, or local laws.

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