Director, Program Integrity (Healthcare Fraud Waste & Abuse)

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 direction of the EVP and CFO, the Director, Program Integrity provides guidance, supervision and assistance to Program Integrity staff members in performing professional level work in detecting, investigating and preventing beneficiary and provider fraud, waste and abuse of the TRICARE program. The Director 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 Director will be TriWest's point of contact for coordinating program integrity activities with federal government agencies, other management support contractors; TriWest's network subcontractors; TriWest's support subcontractors; and management, employees, beneficiaries, and providers of TriWest. The Director is responsible for maintaining appropriate confidentiality for fraud, waste, and abuse cases developed and/or issues 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 in a related field; or certification in fraud investigations or equivalent experience (Accredited Healthcare Fraud Investigator and/or Certified Fraud Examiner)
• A minimum of 5 years of supervisory experience
• U.S. Citizenship
• Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
• 8+ years' investigative experience with 2 - 3 years' experience in detecting, investigating and preventing health care fraud, waste and abuse
• 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
• 3 - 5 years' experience investigating and managing healthcare fraud investigations
• 3 years working for a government investigative agency such as the Office of Inspector General (OIG), Federal Bureau of Investigation (FBI), or Defense Criminal Investigative Service (DCIS), or direct collaboration with a government investigative agency
• Experience in TRICARE, VA, Medicare, and managed care programs

Key Responsibilities

• Maintains a complete understanding of the contractual requirements for the program integrity function through the review of TRICARE, VA Community Care, Medicare, and other Government agency directives and regulations.
• Serves as the focal point for the development of cost and technical proposals for contract modifications impacting TriWest's program integrity activities.
• Develops and implements the necessary policy and procedures documents for TriWest's achievement of the contractual requirements for program integrity.
• Develops and implements an annual training and education program for the management and employees of TriWest and its subcontractors.
• Develops education and training materials for distribution to beneficiaries, Veterans, and providers within the TRICARE region and VA Community Care regions administered by TriWest.
• Assists the VP, Audit & Corporate Compliance in developing and implementing the annual goals, objectives, and strategy for TriWest's program integrity function.
• Monitors the program integrity staff's achievement of productive and qualitative goals and objectives and provides timely periodic feedback to staff on needed improvements and/or achievements.

• Affects the effective use of artificial intelligence antifraud software for detecting provider fraud, waste, and abuse.
• Ensures the accuracy, completeness, and timely submission 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.
• Serves as TriWest's focal point for investigations directed by the Defense Health Agencies and Veterans Affairs Program Integrity Offices and ensures the development of necessary case documentation.
• Ensures that TriWest program integrity staff members are provided continuing professional education on detecting and preventing fraud, waste, and abuse.
• Provides input to management plans (i.e., Quality Management Plan, etc.) on program integrity activities.
• Prepares and presents to internal and external groups the results of program integrity activities.
• Facilitate the development of Program Integrity materials for staff, provider, Veteran and beneficiary education and training as well as assist other departments with Quality Management 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 following customer service goals and guidelines.
• Demonstrate flexibility and adaptability.
• Perform 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.

Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.

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. 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: $141,000 to $ 181,000 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.