We offer remote work opportunity in AZ.

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 have U.S. Citizenship.

Job Summary

The TRICARE Sr Grievance Specialist will review incoming TRICARE grievances, submitted by TRICARE-eligible beneficiaries and/or their designees; researches and compiles facts associated with grievance; refers issues to appropriate subject matter experts and/or operations staff for appropriate action/response/resolution; tracks ongoing research, resolution and/or refinement of responses received; develops written responses (when required) to address TRICARE grievances and/or confirms closure of issue and education/resolution with Beneficiary; follows-up to ensure that systemic issues, processing errors and staff, provider office representative or program user education gaps are addressed; interfaces both orally and in writing with , DHA staff and other DHA stakeholders, TRICARE beneficiaries and their family members or other authorized representatives, provider office staff and internal TriWest staff. The Senior position will also support the Manager, TRICARE Customer Grievances, in supporting other TRICARE Grievances Specialists with casework support and other duties as assigned by the Manager.

Education & Experience

Required:

• Bachelor's degree in political science, communications, business management or equivalent experience
• U.S. Citizenship
• Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
• Minimum of 1-2 years of experience leading or acting as a subject matter expert for programs or processes
• Proven experience in taking the lead in researching and/or responding to escalated issues or complaints
• Strong verbal and written communication skills
• Strong working knowledge of MS Word, Excel and Outlook

Preferred:

• Experience in the health care industry and/or constituent services (state or federal)
• A solid understanding of the Health Insurance Portability and Accountability Act (HIPAA), related privacy laws and security measures (physical storage, open discussions and electronic transmissions) for safeguarding Protected Health Information (PHI) and Personally Identifiable Information (PII).
• Experience working with/for Government agencies, Congressional offices and/or VA Health Care System
• Military experience (Veteran,retiree or military spouse)

Key Responsibilities

• Supports the Manager, TRICARE Customer Grievances, with the workflow processes relating to the workload received by the department.
• Assists in the reviews of draft grievance communications before forwarding to the Manager for approval.
• Assists in the crafting and reviews of draft responses to grievances and routine correspondence.
• Represents the Manager and the department in meetings (at the Manager's discretion).
• Reviews incoming grievance submissions and routine correspondence to determine the most appropriate and effective course of action.
• Conducts thorough research and analysis of targeted issues by accessing multiple TriWest online systems and interfacing with TriWest staff in all functional areas regarding the services provided under TriWest's TRICARE contract.
• Coordinates with and communicates with various TriWest departments, subcontractors, field operational offices TRICARE stakeholders and beneficiaries to obtain information required for substantive/quality responses to grievance submissions and routine correspondence. Reviews departmental responses to grievance submissions to ensure that responses appropriately address the concerns expressed in the inquiry by the beneficiary.

• Helps prepare written responses to inquiries and coordinates all input into planned response prior to managerial review.
• Documents communications with beneficiaries, family members or other authorized representatives, provider office staff members and TRICARE stakeholders.
• Creates and maintains records and files on individual grievances and routine correspondence. Tracks all casework referred to TriWest departments or subcontractors to ensure that all casework has documented outcomes for timely resolution in line with TRICARE program requirements for this workload. Prepares and files casework.
• Maintains logs and other tracking tools to assist department leadership with reporting and leadership decision-making requirements.
• Identifies and reports potential fraud or patient quality issues to the appropriate department.
• Perform 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.

Creativity / Innovation: Ability to develop unique and novel solutions to problems; view change as necessary.

Empathy / Customer Service: Customer-focused behavior; helping approach, including listening skills, patience, respect and empathy for another's position.

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; ability to maintain a realistic understanding of relevant issues and a willingness to discuss specific complaint/grievance cases with department management to ensure all resolution options have been considered.

Technical Skills: Working knowledge of the TRICARE program and related programs that TriWest is contracted to administer for DOD/DHA. Familiarity with Privacy Act and HIPAA requirements that apply to all grievance and routine correspondence scenarios.

Working Conditions

• Availability to work non-regular hours as necessary
• Works within a standard office environment with minimal travel required
• Extensive computer work with long periods of sitting

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

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.