Program Integrity Clinical Spc

**Profile** ----------- 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. Veterans, Reservists, Guardsmen and military family members 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:** * Experience in the preparation and presentation of teaching materials; assessment evaluations, and writing skills * Certified Coder (CPC, CPC\-P, CCA, CCS\-P), AHFI, CFE, or other related certification **Key Responsibilities** * Resource clinician for Program Integrity staff. * Research and investigate medical issues as they relate to potential fraud and abuse cases, to include perform anti\-fraud and abuse pre\-payment reviews or post\-payment reviews. * Conducts medical records and claims reviews for potential fraud and abuse issues, as well as medical necessity, benefit coverage, utilization and quality of care issues and outcomes. * Coordinate and compile written Investigative Summary Reports in conjunction with PI investigators upon completion of records review. * Maintains the confidentiality and non\-discoverability of all fraud and abuse, quality assurance, quality management and risk management issues. * Facilitate and support the Program Integrity Goals and Objectives. * Readily accesses and interprets TRICARE and Medicare coverage guidelines, policies and procedures as well as TriWest policies and procedures. * Effective utilization of the antifraud artificial intelligence software. * Effective utilization of all documentation systems related to fraud and abuse activities and reporting systems. * Participates in DHA directed investigation, data collection and medical record reviews for f