Profile
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 & 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
Reviews medical documentation and claims to ensure Applied Behavior Analysis (ABA) provider compliance with contract and program requirements for the Autism Care Demonstration (ACD) in the TRICARE West Region. The role helps to ensure quality care is delivered for TRICARE beneficiaries by identifying evaluating medical records and claims retrospectively for potential quality, safety, utilization, or billing issues by using organizational, national, and TRICARE standards for consistency. Supports activities of peer review and quality and safety committees.
Education & Experience
Required:
- Registered Nurse or Licensed Clinical Social Worker, with current unrestricted license in appropriate state
- U.S. Citizenship
- Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation.
- 3 years clinical experience (pediatrics, and/or behavioral health)
Preferred
- Bachelor’s degree in nursing or other health care field
- 1 year experience in clinical document auditing
- 1 year experience with data analysis and reporting
- Experience with Applied Behavior Analysis (ABA) or with
- General knowledge of Medicare, TRICARE, or other government healthcare programs
Key Responsibilities
- Clinical review of ABA provider documentation to assess quality and adherence to program requirements.
- Identifies Potential Quality Issues (PQIs) by performing a timely review of the medical records.
- Identifies opportunities for provider education and accomplishes outreach to providers/groups with inconsistencies or errors identified.
- Assists the company with the initiation of progressively more severe administration action, commensurate with the seriousness of the identified problems
- Administrative review of ABA claims for detection and prevention of fraud and abuse to the TRICARE Program and beneficiaries, to include a review of suspect billing practices and document risks to determine improper payments in the ACD program.
- Identification and initiation of recoupments of claims dollars paid
- Develops peer review cases and other quality improvement activities for monitoring deviations from accepted standards of care and suggesting corrective action plans.
- Collaborate with Clinical Quality Management (CQM) on Practice Pattern Analyses if applicable.
- Identifies focused review topics to Clinical Quality Management Leadership.
- Performs focused study data collection, reporting, analysis, and makes recommendations for improvement.
- Refers cases for review as appropriate to Program Integrity, Case Management, Care Coordination, Population Health Improvement, Disease Management, Congressional Relations & Customer Grievances and other TriWest departments.
- Participates on quality committees.
- Reviews Potential Quality Issues with Medical Directors when appropriate.
- Performs other duties as assigned.
- Regular and reliable attendance is required.
Competencies
Commitment to Task: Ability to conform to established policies and procedures; exhibit high motivation.
Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.
Independent Thinking / Self-Initiative: Critical thinkers with ability to focus on things which matter most to achieving outcomes; Commitment to task to produce outcomes without direction and to find necessary resources.
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.
Technical Skills: General knowledge of Medicare, TRICARE, or other government health care programs; knowledge in the application of clinical criteria: InterQual, PAS-LOS, ICD-9-CM, DSM, CPT-4, and HCPCs; Proficient with Microsoft Word and Excel
Working Conditions
Working Conditions
- Ability to cover any work shift
- Onsite: Works within a standard office environment
- Remote: Private and secure work space and work station with high speed internet is required.
- Extensive computer work with prolonged sitting, wearing of headset, typing, speaking on a phone
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:
- Medical, Dental and Vision Coverage
- Generous paid time off
- 401(k) Retirement Savings Plan (with matching)
- Short-term and long-term disability, basic life, and accidental death and dismemberment insurance
- Tuition reimbursement
- Paid volunteer time
*Annual base salary for Colorado, Hawaii, Washington D.C. and Washington State residents: Approx. $82,000 depending on experience*
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 cultivates and supports diversity at every organizational level, including hiring and retaining a diverse workforce, and we highly encourages candidates from all backgrounds to apply. Applicants are considered for positions 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.
