Utilization Clinical Reviewer - Appeals
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
The Utilization Management Clinical Review nurse reviews and makes decisions about the appropriateness and level of beneficiary care being provided in an effort to provide cost effective care and ensure proper utilization of resources. Applies clinical knowledge to make determinations for preauthorization, inpatient and continued stay reviews for Behavioral Health and Medical/Surgical requests to establish medical necessity, benefit coverage, appropriateness of quality of care, and length of stay or care plan. Utilizes clinical criteria and policy keys to complete review. Documents in the medical management information system. Prepares and presents more complex cases for Medical Director Review. Refer cases to Case Management and Disease Management as appropriate. Advises non-clinical staff on clinical and coding questions. Conducts pre-admission screening and assessments.
Education & Experience
Required:
Active, unrestricted RN license
U.S. Citizen
Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
2+ years clinical experience
2+ years UM experience
Proficient computer skills including Microsoft Office Suite (Teams, Word, Excel and outlook)
Demonstrates effective verbal and written communication skills
Preferred:
3+ years Medical / Surgical experience
Behavioral Health experience
1 year TriWest or TRICARE experience
Managed Care experience
Key Responsibilities
Conducts prior authorization, continued stay, and referral management activities.
Assesses medical necessity by screening available information against established criteria, using InterQual Clinical Guidelines Policy Keys and Behavioral Health criteria.
Interprets information and makes decision whether authorizations align with the TriWest benefit program.
Ensures timely reviews for requesting facilities and appropriate notification to parties.
Contacts beneficiary and / or provider to obtain or clarify medical information as necessary.
Refers cases to Case Management, Care Coordination, or Disease Management for review as necessary.
Prepares cases for Medical Director and Peer Review according to established policy.
Refers potential quality issues and complaints to Clinical Quality Management.
Notifies Internal Audit & Corporate Compliance department of cases for review of potential fraud.
Maintain compliance with Federal, State and accreditation organizations.
Performs other duties as assigned.
Regular and reliable attendance is required.
Competencies
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.
Empathy / Customer Service: Customer-focused behavior; Helping approach, including listening skills, patience, respect, and empathy for another's position.
Independent Thinking / Self-Initiative: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.
High Intensity Environment: Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.
Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented
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, Utilization Management principles, Managed Care concepts, medical terminology, medical management system, InterQual criteria, working knowledge of medical coding
Working Conditions
Working Conditions:
Ability to cover any work shift
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
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: $73,000 - $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.
Apply Now
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
The Utilization Management Clinical Review nurse reviews and makes decisions about the appropriateness and level of beneficiary care being provided in an effort to provide cost effective care and ensure proper utilization of resources. Applies clinical knowledge to make determinations for preauthorization, inpatient and continued stay reviews for Behavioral Health and Medical/Surgical requests to establish medical necessity, benefit coverage, appropriateness of quality of care, and length of stay or care plan. Utilizes clinical criteria and policy keys to complete review. Documents in the medical management information system. Prepares and presents more complex cases for Medical Director Review. Refer cases to Case Management and Disease Management as appropriate. Advises non-clinical staff on clinical and coding questions. Conducts pre-admission screening and assessments.
Education & Experience
Required:
Active, unrestricted RN license
U.S. Citizen
Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
2+ years clinical experience
2+ years UM experience
Proficient computer skills including Microsoft Office Suite (Teams, Word, Excel and outlook)
Demonstrates effective verbal and written communication skills
Preferred:
3+ years Medical / Surgical experience
Behavioral Health experience
1 year TriWest or TRICARE experience
Managed Care experience
Key Responsibilities
Conducts prior authorization, continued stay, and referral management activities.
Assesses medical necessity by screening available information against established criteria, using InterQual Clinical Guidelines Policy Keys and Behavioral Health criteria.
Interprets information and makes decision whether authorizations align with the TriWest benefit program.
Ensures timely reviews for requesting facilities and appropriate notification to parties.
Contacts beneficiary and / or provider to obtain or clarify medical information as necessary.
Refers cases to Case Management, Care Coordination, or Disease Management for review as necessary.
Prepares cases for Medical Director and Peer Review according to established policy.
Refers potential quality issues and complaints to Clinical Quality Management.
Notifies Internal Audit & Corporate Compliance department of cases for review of potential fraud.
Maintain compliance with Federal, State and accreditation organizations.
Performs other duties as assigned.
Regular and reliable attendance is required.
Competencies
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.
Empathy / Customer Service: Customer-focused behavior; Helping approach, including listening skills, patience, respect, and empathy for another's position.
Independent Thinking / Self-Initiative: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.
High Intensity Environment: Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.
Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented
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, Utilization Management principles, Managed Care concepts, medical terminology, medical management system, InterQual criteria, working knowledge of medical coding
Working Conditions
Working Conditions:
Ability to cover any work shift
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
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: $73,000 - $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.
Apply Now