Applied Behavioral Analyst - Quality Monitor Clinician

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

Job summary

An established industry player is seeking an Applied Behavioral Analyst to ensure compliance and quality in healthcare services for veterans. This remote role involves reviewing medical documentation, conducting audits, and collaborating with various departments to enhance care delivery. If you have a passion for serving those who served and possess a strong clinical background, this position offers a unique opportunity to make a significant impact in the lives of TRICARE beneficiaries. Join a team that values teamwork, offers competitive pay, and provides a supportive work environment.

Benefits

Medical, Dental and Vision Coverage

Generous paid time off

401(k) Retirement Savings Plan

Tuition reimbursement

Paid volunteer time

Qualifications

• 3+ years clinical experience in pediatrics or behavioral health.
• Registered Nurse or Licensed Clinical Social Worker with an active license.

Responsibilities

• Review ABA provider documentation for quality and compliance.
• Conduct clinical reviews and identify potential quality issues.
• Collaborate with Clinical Quality Management on analyses.

Skills

Clinical Experience

Data Analysis

Problem Solving

Organizational Skills

Education

Registered Nurse License

Bachelor's Degree in Nursing

Tools

Microsoft Word

Microsoft Excel

InterQual

Job description

Applied Behavioral Analyst - Quality Monitor Clinician (Finance)

Applied Behavioral Analyst - Quality Monitor Clinician (Finance)

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 with
• 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 a timely review of the medical records.
• Identifies opportunities for provider education and accomplishes outreach to providers/groups with inconsistencies or errors identified.
• Assists the company with the initiation of progressively more severe administration action, commensurate with the seriousness of the identified problems
• Administrative review of ABA claims for detection and prevention of fraud and abuse to the TRICARE Program and beneficiaries, to include a review of suspect billing practices and document risks to determine improper payments in the ACD program.
• Identification and initiation of recoupments of claims dollars paid
• Develops peer review cases and other quality improvement activities for monitoring deviations from accepted standards of care and suggesting corrective action plans.
• Collaborate with Clinical Quality Management (CQM) on Practice Pattern Analyses if applicable.
• Identifies focused review topics 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.

Competencies

Commitment to Task: Ability to conform to established policies and procedures; exhibit high motivation.

Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.

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.

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.

Technical Skills: General knowledge of Medicare, TRICARE, or other government health care programs; knowledge in the application of clinical criteria: InterQual, PAS-LOS, ICD-9-CM, DSM, CPT-4, and HCPCs; Proficient with Microsoft Word and Excel

Working Conditions

Working Conditions:

• Ability to cover any work shift
• 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

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

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 $75,000 - $96,000 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 s candidates from all backgrounds to apply. Applicants are considered for positions based on merit and 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.