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 and 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 and Experience

Required:

High School Diploma or GEDU.S. CitizenshipMust be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigationHealthcare claim processing or billing experienceKnowledge of HCFA 1500 and UB-04 claim forms and fieldsStrong MS Excel skills, to include basic analysis functionsPreferred:

Experience with FACETS claim processing applicationKnowledge of Fraud, Waste and Abuse investigationsKnowledge of medical record review and documentation requirementsKnowledge of Medicare policies and guidelinesClaim coding experienceCustomer 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 resolutio .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 proce