Job Description:

We offer remote work opportunities for this position in the following states: AZ, CA, *CO, ID, NV, NM, OR, UT, *WA.

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

Supervises daily Utilization Management (UM) program operations. This position reports to a Manager of Utilization Management in either Prospective, Retrospective, or Appeals and Reconsideration for the TRICARE contract. The supervisor coordinates across teams to support meeting contractual metrics and timeliness, standardized clinical care requirements and accreditation standards. This position is responsible for supervision of UM performance and staff management. Development and preparation of operational reports. Functions as backup for staff during high volume periods.

Education & Experience

Required:

• Registered Nurse, with current valid, unrestricted nursing license
• 3+ years of job related experience in a healthcare environment
• 3+ years supervisory or leadership experience in a healthcare environment
• 2+ years utilization review or case management
• U.S. Citizenship
• Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation

Preferred:

• Medical/Surgical or Behavioral Health experience
• Commercial Managed Care experience
• Knowledge of government health care programs
• Familiarity with utilization review criteria
• CCM or HCQM certification
• Knowledge of medical billing and coding
• Prior experience with remote work environments

Key Responsibilities

• Supervises day to day UM operations to ensure operational effectiveness and efficiency.
• Ensures staff is fully-informed of changes by communicating updates, policy revisions, performance outcomes, and significant events.
• Prepares work schedules and monitors staff caseloads to ensure adequate staffing levels at all times and accurate data entry and application of the medical management system.
• Monitors staff to ensure adherence to established criteria, including InterQyal, internally developed guidelines, decision support tools, contract requirements and TriWest policies and desk procedures.
• Prepares reports for tracking and trending of UM activities.
• Interprets reports and identifies UM opportunities to share with management.
• Monitors the UM process and identifies and implements process improvements to ensure program quality assurance and compliance.
• Reports Potential Quality Issues (PQI).
• Responsible for interviewing and hiring new staff.
• Provides coaching and oversight to staff to ensure staff success and development.
• Assists with implementation, orientation and training of new staff.
• Assists with the development of desk procedures, processes, workflow changes, and reports.
• Systematically evaluates the quality and effectiveness of staff performance.
• Advises and coaches when appropriate and completes annual performance appraisals.
• Participates in meetings as required.
• Collaborates across the clinical operations team for enhancing service levels.
• Coordinates activities with contracted partners to meet Utilization Management (UM) Plan goals.
• Completes special projects.
• Regular and reliable attendance.
• Performs other duties as assigned.

Competencies

Coaching / Training / Mentoring: Actively foster actions required for desired business outcomes through ongoing constructive feedback.

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.

Delegation Skills: Provide clear performance expectations for projects and ensure adequate access to resources for completion

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.

Leadership: Successfully manage different styles of employees; provide clear direction and effective coaching.

Multi-Tasking / Time Management: Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environment.

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: Thorough knowledge of policies and procedures, knowledge of managed care principles and methods; medical terminology; proficiency in the application of clinical criteria: InterQual, International Classification of Diseases, Diagnostic and Statistical Manual of Mental Disorders, current Procedural Terminology, and Healthcare Common Procedural Coding System, and American Dental codes; working knowledge with medical management systems; proficient with Microsoft Office; knowledge of UM Process; reporting techniques.

Working Conditions

Working Conditions:

• Works non-regular hours, as required
• Works remotely, with up to 10% travel
• Ability to meet mandatory contract compliance timelines
• Extensive computer work with prolonged 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.

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 and Washington State residents: $101,000 - $129,000 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.

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