Education & Experience Required:

RN or LCSW (Independently Licensed Clinical Social Worker) with current unrestricted license in appropriate state or territory of the United States
If supporting TRICARE contract, must be a U.S. Citizen
If supporting TRICARE contract, must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
5+ years of clinical experience in a variety of settings (behavioral health and medical/surgical)
2+ years of supervisory experience
1+ year of experience in Quality Management to include conducting medical records abstracting and quality investigations

Preferred:

Bachelor's degree in Nursing Health Administration, health-related field or equivalent and experience
Certified Professional in Healthcare Quality (CPHQ)
General knowledge of nationally recognized standards of care, Interqual, CMS, HEDIS, AHRQ, TRICARE, or government health care programs
General knowledge of Medicare, TRICARE, or government health care programs Key Responsibilities
Supervises Clinical Quality clinical and non-clinical daily operations and ensures timeliness and accuracy of work to meet all contract requirements. Hires, coaches, counsels, evaluates, and develops clinical and non-clinical staff. Supports recruitment efforts by interviewing, selecting, and training new staff.
Ensures that new staff are fully onboarded and trained. Conduct regular 1: 1 and team meetings to ensure alignment to work requirements, timely communication and performance management.
Supervises individual staff caseload and beneficiary needs to ensure timely delivery of care as well as productivity and timeliness requirements. Assigns cases appropriately according to clinicians' scope of practice.
Monitors and ensures appropriate and accurate focused study data collection, analysis, and reporting.
Develops and maintains training modules on quality management basics for teaching staff.
Conducts performance evaluations and develops performance improvement plans as necessary.
Identifies, develops, and monitors focused reviews and other quality studies. Keeps Manager informed of issues related to quality studies and PQIs.
Provides accurate communications on case reviews.
Performs staff audits and develops summary reports.
Ensures adherence to accreditation standards, TRICARE policy, contractual requirements and nationally recognized practice standards.
Facilitates working case review meetings.
Conducts Potential Quality Issue (PQI) investigations by performing a timely and complete case analysis. Maintains a consistent PQI caseload of 2 - 5 cases.
Requests query reports, as appropriate, and analyze data supporting focused reviews and quality studies.
Refers cases for review as appropriate to and from Program Integrity, Case Management, Provider Services, Congressional and Customer Relations, and other TriWest departments.
Participates on TriWest committees as a representative of Clinical Quality Management.
Performs other duties as assigned.
Regular and reliable attendance is required.

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.

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:

Comprehensive knowledge of research methodology; proficient applying appropriate data analysis processes; knowledge of managed care principles and methods; knowledge in the application of clinical criteria; proficient with Microsoft Word, Excel, and PowerPoint.

Working Conditions Working Conditions:

Telecommute with minimal travel
Ability to use a computer and sit for prolonged periods 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 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 $100, 000 to $111, 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. 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