Director, Program Integrity (Healthcare Fraud Waste & Abuse)

About the position 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. The role requires 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. The Director will develop and implement necessary policy and procedures documents for TriWest's achievement of the contractual requirements for program integrity. Additionally, the Director will develop and implement an annual training and education program for the management and employees of TriWest and its subcontractors, ensuring that all staff members are provided continuing professional education on detecting and preventing fraud, waste, and abuse. The Director will also monitor the program integrity staff's achievement of productive and qualitative goals and objectives, providing timely feedback on needed improvements and/or achievements. This position requires interfacing with TriWest functional areas and claims processing subcontractors as needed on fraud, waste, and abuse cases, and serving as TriWest's focal point for investigations directed by the Defense Health Agencies and Veterans Affairs Program Integrity Offices. Regular and reliable attendance is required, and the Director must demonstrate flexibility and adaptability in a high-volume, high-stress environment. Responsibilities • Provide guidance, supervision, and assistance to Program Integrity staff members. , • Detect, investigate, and prevent beneficiary and provider fraud, waste, and abuse of the TRICARE program. , • Coordinate program integrity activities with federal government agencies and other contractors. , • Maintain confidentiality for fraud, waste, and abuse cases. , • Develop and implement necessary policy and procedures documents for program integrity. , • Develop and implement an annual training and education program for management and employees. , • Monitor program integrity staff's achievement of goals and provide feedback. , • Interface with TriWest functional areas and claims processing subcontractors on fraud cases. , • Prepare and present results of program integrity activities to internal and external groups. Requirements • Bachelor's degree in healthcare administration, business administration, criminal justice, management or related field from an accredited institution; or certification in fraud investigations or equivalent experience. , • 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. Nice-to-haves • 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). , • Experience in TRICARE, VA, Medicare, and managed care programs. Benefits • 401(k) , • 401(k) matching , • AD&D insurance , • Dental insurance , • Disability insurance , • Health insurance , • Paid time off , • Tuition reimbursement , • Paid volunteer time Apply Job!