Program Integrity Clinical Specialist

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 managem...