Profile
Veterans, Reservists, Guardsmen and military family members are encouraged to apply!!
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, TX, UT, VA/DC, *WA, WI & WY only)
Job Summary
This individual contributor position reports to the Directors of Utilization Management (UM) and Referral Management (RM) and supports both RM and UM program processes. Develops training materials, desk procedures, conducts standards of practice research and focused studies; and conducts process audit. Trains staff on RM and UM processes and assists with monitoring adherence to UM accreditation standards. Coordinates Policy Key development and revision; manages ongoing research and coding for the Referral and Authorization Decision Support (RADS) tool; and plays a significant role with ongoing development of key processes and techniques for measuring outcomes.
Education & Experience
Required:
- Registered Nurse, with current unrestricted license in appropriate state
- 4+ years Utilization Management experience
- Proficient at in-depth analysis of clinical policy and medical records for appropriateness of care and/or level of care criteria required
Preferred
- TRICARE experience
- Qualified for Certified Professional Utilization Review Certification or Certified Professional Utilization Management Certification
- Experience in UM policy writing, development, training, and/or auditing
- Experience with clinical coding research
- Experience with managed care programs and processes
Key Responsibilities
- Researches TRICARE policy, operations, reimbursement manuals and appropriate clinical criteria resources to support development of Policy Keys, clinical guidelines and coding for the RADS tool.
- Participates with Contract Modification meetings and processes as a UM and/or RM Subject Matter Expert
- Trains staff to use established criteria for evaluating medical necessity and appropriateness of care, including InterQual, Policy Keys, and consulting the RADS tool.
- Trains staff in techniques for validating medical determinations through research, regulatory manuals, computer files, and medical documentation.
- Assists staff with complex, in-depth analysis and review of UM processes.
- Develops and maintains UM and RM desk procedures ensuring compliance with TRICARE Operational Manuals and best practices.
- Trains staff to determine RM process resolution to include data, eligibility, optimization or provider search issues using appropriate resources.
- Works with training, and clinical leaders to develop, maintain and assess RM and UM resource tools to support accuracy and efficiency.
- Works with Clinical Operations Managers and Directors to develop and implement audit tools for evaluating staff compliance desk procedures and accreditation standards.
- Assists with developing UM and RM productivity and performance measures.
- Completes periodic focused studies and performance audits.
- Assists in department preparation for the URAC accreditation survey.
- Functions as Subject Matter Expert on UM and RM.
- Participates in special projects and cross-functional teams.
- Performs other duties as assigned.
- Regular and reliable attendance is required.
Competencies
Coaching / Training / Mentoring: Actively foster actions required for desired business outcomes through ongoing constructive feedback.
Commitment to Task: Ability to conform to established policies and procedures; exhibit high motivation.
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 function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.
Coping / Flexibility: Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required.
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.
Information Management: Ability to manage large amounts of complex information easily, communicate clearly, and draw sound conclusions.
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, Advanced knowledge of UM and RM principles, Managed Care concepts, medical terminology, medical management system, Intensity of Service and Severity of Illness indexes, InterQual Imaging Criteria, Procedural Criteria, Level of Care, and Length of Stay, International Classification of Diseases, Current Procedural Terminology, Health Care Financing Administration Common Procedure Coding System, and American Dental coding, reporting techniques.
Working Conditions
Working Conditions
- Availability to work any shift
- Regular and reliable attendance
- Works within a standard office environment, with minimal travel
- Extensive computer work with prolonged sitting
- Department of Defense security clearance required
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.
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 and Washington State residents: $87,882 - $107,755 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.
