Profile
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
This position is under general guidance of the Director, Program Integrity and reports directly to the Supervisor, PI Specialist. The PI Support Specialist is responsible for providing claim processing and administrative support for Program Integrity (PI) investigations, law enforcement requests for information, other internal/external Fraud, Waste and Abuse (FWA) case development activities. The PI Support Specialist utilizes healthcare billing, claim processing, and medical record knowledge, in addition to research skills, to review and process of medical/surgical and behavioral health claims according to protocol directions established by PI Specialist. The PI Support Specialist captures savings and recoupment calculations, and reports on PI provider flag efficiencies. The PI Support Specialist compiles claim data, provider contracts, bank accounts, patient files (including, but not limited to medical records and claim images) and other information necessary to respond to law enforcement subpoenas related to FWA investigations. The PI Support Specialist accurately records case referrals, claim activity, and law enforcement information requests, and assists the PI Supervisor with departmental reporting requirements. Ensures strict compliance with court appearance deadlines and HIPAA Privacy Rules.
Education & Experience
Required:
- High School Diploma or GED
- U.S. Citizenship
- Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
- Healthcare claim processing or billing experience
- Knowledge of HCFA 1500 and UB-04 claim forms and fields
- Strong MS Excel skills, to include basic analysis functions
Preferred
- Experience with FACETS claim processing application
- Knowledge of Fraud, Waste and Abuse investigations
- Knowledge of medical record review and documentation requirements
- Knowledge of Medicare policies and guidelines
- Claim coding experience
- Customer Service or Call Center experience
Key Responsibilities
- Works with PI Specialist to ensure understanding of the case allegations, investigation and findings, and applies understanding to achieve claim review protocol goals.
- Processes claims, ensuring compliance with contract timeline requirements for claim resolution, meeting defined accuracy metrics.
- Creates claim logs to track and analyze claim submissions, and prepares reports for PI Supervisor on efficiencies, savings, and recoupments.
- Advises PI Specialist of observed changes in billing patterns.
- Recommends process improvements related to all aspects of claims payment and medical documentation requests.
- Works with TriWest Data Management, Provider Services, and Legal teams; TriWest vendors; and law enforcement agencies to coordinate timely responses to subpoenas and other requests for investigative assistance.
- Compiles and audits document packages, to ensure complete and accurate files that fully satisfy subpoena requirements.
- Responds to incoming hotline calls, and prepares referrals for case development.
- Researches and resolves inquiries that do not require fraud, waste and abuse investigation.
- Enters new referral information into case management system and tracks investigative, claim, other internal workgroup, and law enforcement activities through to case resolution.
- Assists PI Supervisor with required reporting of case referrals, activities, and results.
- Communicates effectively with management and peers.
- Identifies and reports any potential quality or fraud issues to management, Quality Management or Program Integrity leadership as appropriate.
- Performs 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.
Commitment to Task: Ability to conform to established policies and procedures; exhibit high motivation.
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 Excel, Word, Outlook, TriWest Intranet, the Internet, and department software applications.
Coping / Flexibility: Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required.
High Intensity Environment: Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.
Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.
Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment.
Technical Skills: Thorough knowledge of policies and procedures, Managed Care concepts and medical terminology. Proficient with claim and coding tools such as Find-A-Code, Current Procedural Terminology, Health Care Common Procedure Coding System, and ICD-10 Diagnosis Coding. Knowledge of medical record documentation. Ability to meet or exceed production standards in compliance with contract.
Working Conditions
Working Conditions
- Favorable working conditions in a climate controlled office space
- Must be available to cover any work shift
- Works within an office environment with minimal travel required
- Level II IT security clearance
- Extensive computer work with prolonged sitting
- Security clearance as required by contract
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: $63,000- $81,000 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.
