Applied Behavioral Analyst - Quality Monitor Clinician

TriWest Healthcare Alliance; Phoenix (AZ); Remote; USD 75,000 - 96,000; Full time

Job summary

An established industry player is seeking an Applied Behavioral Analyst to ensure quality care for TRICARE beneficiaries. This role involves reviewing medical documentation and claims to verify compliance with program requirements. The ideal candidate will have clinical experience, strong analytical skills, and the ability to identify quality issues. Join a mission-driven organization dedicated to serving veterans and their families, offering remote work opportunities and a comprehensive benefits package. If you are passionate about making a difference in healthcare, this is the perfect opportunity for you.

Benefits

Medical Insurance

Dental Insurance

Vision Insurance

401(k) with Matching

Paid Time Off

Tuition Reimbursement

Paid Volunteer Time

Disability Insurance

Life Insurance

Qualifications

• 3 years clinical experience in pediatrics or behavioral health required.
• Registered Nurse or Licensed Clinical Social Worker with a current license.

Responsibilities

• Review ABA provider documentation for quality and adherence to requirements.
• Identify potential quality issues through timely medical record reviews.

Skills

Clinical Experience

Data Analysis

Problem Solving

Communication Skills

Organizational Skills

Education

Registered Nurse License

Bachelor's Degree in Nursing or Health Care Field

Tools

Microsoft Word

Microsoft Outlook

Department Software

Job description

Applied Behavioral Analyst - Quality Monitor Clinician

Join to apply for the Applied Behavioral Analyst - Quality Monitor Clinician role at TriWest Healthcare Alliance.

Profile

We offer remote work opportunities (AK, AR, AZ, 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
Reviews medical documentation and claims to ensure Applied Behavior Analysis (ABA) provider compliance with contract and program requirements for the Autism Care Demonstration (ACD) in the TRICARE West Region. The role helps to ensure quality care is delivered for TRICARE beneficiaries by identifying, evaluating medical records, and claims retrospectively for potential quality, safety, utilization, or billing issues by using organizational, national, and TRICARE standards for consistency. Supports activities of peer review and quality and safety committees.

Education & Experience
Required:

• Registered Nurse or Licensed Clinical Social Worker, with current unrestricted license in appropriate state
• U.S. Citizenship
• Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
• 3 years clinical experience (pediatrics, and/or behavioral health)

Preferred:

• Bachelor’s degree in nursing or other health care field
• 1 year experience in clinical document auditing
• 1 year experience with data analysis and reporting
• Experience with Applied Behavior Analysis (ABA) or related fields
• General knowledge of Medicare, TRICARE, or other government healthcare programs

Key Responsibilities

• Clinical review of ABA provider documentation to assess quality and adherence to program requirements.
• Identifies Potential Quality Issues (PQIs) by performing timely reviews of medical records.
• Identifies opportunities for provider education and outreach regarding inconsistencies or errors.
• Assists in initiating administrative actions based on severity of identified problems.
• Reviews ABA claims for fraud detection and prevention, including suspect billing practices and improper payments.
• Initiates recoupments of claims dollars paid in error.
• Develops peer review cases and quality improvement activities, suggesting corrective actions.
• Collaborates with Clinical Quality Management on Practice Pattern Analyses if applicable.
• Identifies review topics for Clinical Quality Management leadership.
• Performs data collection, reporting, analysis, and recommends improvements.
• Refers cases for review to relevant departments as appropriate.
• Participates in quality committees and reviews Potential Quality Issues with Medical Directors.
• Performs other duties as assigned.
• Maintains regular and reliable attendance.

Competencies

• Commitment to Task: High motivation and adherence to policies
• Computer Literacy: Proficient in Microsoft Word, Outlook, and department software
• Independent Thinking / Self-Initiative: Critical thinking and resourcefulness
• Organizational Skills: Ability to manage tasks within time constraints
• Problem Solving / Analysis: Systematic process analysis and sound judgment
• Technical Skills: Knowledge of Medicare, TRICARE, clinical criteria, and proficient with Microsoft Office

Working Conditions

• Ability to cover any work shift
• Onsite: Standard office environment
• Remote: Private workspace with high-speed internet
• Prolonged computer use, sitting, headset use, speaking on phone

Company Overview

Taking Care of Our Nation’s Heroes. It’s Who We Are. It’s What We Do.
Join TriWest Healthcare Alliance and be part of our mission to serve those who served. Since 1996, we’ve been connecting America’s heroes to healthcare in the community.

Benefits

We offer comprehensive compensation and benefits including medical, dental, vision, paid time off, 401(k) with matching, disability and life insurance, tuition reimbursement, and paid volunteer time. The salary range for this position is approximately $75,000 - $96,000 annually, depending on role and location.

TriWest is an equal opportunity employer promoting diversity and inclusion. We encourage candidates from all backgrounds to apply.