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

We offer remote work opportunities (AK, AR, AZ, 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.

Veteran, Military Spouse or Military Affiliated are encouraged to apply!

Job Summary

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

Education & Experience

Required :

• 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

Preferred :

Key Responsibilities

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 manage large amounts of complex information easily, communicate clearly, and draw sound conclusions.

Delegation Skills : Provide clear performance expectations for projects and ensure adequate access to resources for completion.

High Intensity Environment : Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.

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

Organizational Skills : Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.

Problem Solving / Analysis : Ability to solve problems through systematic analysis of processes with sound judgment; has a realistic understanding of relevant issues.

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

Technical Skills : Knowledge of TRICARE policies and procedures, knowledge of Case Management, Utilization Management, and Quality Management practices and principles, and knowledge of Managed Care concepts, alternative care treatments, and community resources. Proficient with Current Procedural Terminology coding.

Working Conditions

Working Conditions :

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 :

TriWest job postings typically include a salary range, which can vary based on the specific role and location, but generally this position ranges from around $90,000 to $95,000 per year.

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 supports diversity at every organizational level, and we highly encourage candidates from all backgrounds to apply. Applicants are considered for positions based on merit and 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.