Job Description

This position is fully remote.

This position requires a Registered Nurse or Licensed Clinical Social Worker, with current unrestricted license in appropriate state

The Clinical Quality Reviewer 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.

• 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.

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 Bachelors 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

• 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.
• Problem Solving / Analysis
• Ability to solve problems through systematic analysis of processes with sound judgment; has a realistic understanding of relevant issues.
• Organizational Skills
• Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; Detail-oriented.
• The ability to reason logically, evaluate, and analyze information, formulate conclusions, and effectively present both orally and in writing.
• 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.
• Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.
• Ability to conform to established policies and procedures; exhibit high motivation.
• 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

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

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