TRICARE Clinical Quality Reviewer

Job Summary

Ensures compliance with the contract, and program requirements for Clinical Quality Management (CQM) within TRICARE West Region. To ensure quality care is delivered for TRICARE beneficiaries by identifying, investigating, and evaluating medical records retrospectively for potential quality, safety, and utilization issues by using organizational, national, TRICARE, and URAC standards for consistency. Supports activities of peer review and quality and safety committees.

Education & Experience

Required

• H. S. diploma or GED
• Registered Nurse or Licensed Clinical Social Worker, with current unrestricted license in appropriate state
• 3 years clinical experience (medical/surgical, and or behavioral health)
• U. S. Citizenship
• Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation

Preferred

• Bachelor's in Nursing or Bachelor’s degree in a health care field or Certified Professional in Healthcare Quality (CPHQ)
• 1 year experience in Clinical Quality Management
• 1 year experience with data analysis and reporting
• Experience with InterQual criteria or similar criteria sets
• General knowledge of Medicare, TRICARE, or other government healthcare programs

Key Responsibilities

• Identifies Potential Quality Issues (PQIs) by performing a timely review of the medical records. This includes researching, investigating, analyzing, and preparing case summaries with appropriate recommendations for further actions.
• Develops peer review cases and other quality improvement activities for monitoring deviations from accepted standards of care and suggesting corrective action plans.
• Responds to AHRQ concerns and documents a rationale for cases when TriWest's position does not concur with the AHRQ position.
• Requests Practice Pattern Analyses (trend) to assist with identifying physician practice patterns for confirmed severity cases.
• Identifies and refers cases for focused reviews 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.

Information Management: The ability to reason logically, evaluate, and analyze information, formulate conclusions, and effectively present both orally and in writing.

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-10-CM, DSM, CPT, and HCPCS; proficient with Microsoft Word and Excel.

Working Conditions

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.

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 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

TriWest job postings typically include a salary range, which can vary based on the specific role and location, but generally this position ranges from around $79,000 - $93,000 per year.

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 supports diversity at every organizational level, and we highly encourage candidates from all backgrounds to apply. Applicants are considered for positions based on merit and 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.