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!
Must be a United States Citizen.
Job Summary
Conducts focused reviews, quality studies, and quality improvement projects according to appropriate contract standards. Investigates medical records retrospectively for potential quality and utilization issues. Ensures compliance with the program requirements for Clinical Quality Management (CQM) for Veterans and/or DoD beneficiaries. Maintains URAC standards in work products.
Education & Experience
Required:
- Registered Nurse with current unrestricted license in appropriate state
- 1 year experience in Quality Management
- 1 year experience in data analysis and writing clinical quality studies
- 5 years Medical/Surgical experience
- US citizenship and a favorably adjudicated DOD background investigation if selected to work under TRICARE/DoD Contract
Preferred
- Bachelor’s degree in Nursing or CPHQ
- Experience with team facilitation and project management
- Experience with Medicare, Veteran’s Administration, TRICARE, or other government health care programs
Key Responsibilities
- Conducts research and writes clinical quality studies to identify, develop and evaluate processes to improve delivery of care to Veterans and/or DoD beneficiaries.
- Acts as facilitator on quality improvement team projects and utilizes appropriate quality improvement methodologies and standardized quality management tools.
- Leads and performs quality management audits.
- Identifies, develops, and monitors focused reviews and other quality studies.
- Identifies Potential Quality Issues (PQIs) by performing a timely review of the medical records. This includes researching, investigating, analyzing, and preparing case summaries with recommendations for further review.
- Reviews Potential Quality Issues with Medical Directors when appropriate.
- Prepares peer reviewed cases for quality committees and monitors corrective action plans.
- Uses data management software to identify physician practice patterns, over- and under-utilization of care and services, complication rates, and high-cost outliers.
- Prepares and submits activity and projects reports.
- 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.
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.
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, Veteran’s Administration, TRICARE, or other government health care programs; knowledge in the application of clinical criteria; proficient with Microsoft Word, Excel, and PowerPoint.
Working Conditions
- Ability to work overtime, if needed
- 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.
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: $84,000 - $93,000 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.
