Clinical Quality Reviewer

TriWest Healthcare Alliance; Phoenix (AZ); Remote; USD 85,000 - 90,000; Full time

Job summary

TriWest Healthcare Alliance is seeking a Clinical Quality Management Specialist to ensure compliance with contract requirements for quality care for Veterans. The role involves identifying quality issues, supporting peer review activities, and requires a Registered Nurse or Licensed Clinical Social Worker with clinical experience in a healthcare setting, alongside a commitment to provide high-quality care.

Benefits

Medical, Dental and Vision Coverage

Generous paid time off

401(k) Retirement Savings Plan (with matching)

Short-term and long-term disability insurance

Basic life and accidental death insurance

Qualifications

• 3 years clinical experience required (medical/surgical or behavioral health).
• Experience in quality management and data analysis preferred.
• Knowledge of Medicare and Veterans Administration protocols.

Responsibilities

• Ensures compliance with clinical quality management contract requirements.
• Identifies and evaluates potential quality issues.
• Supports activities of peer review and quality safety committees.

Skills

Critical Thinking

Detail-oriented

Problem Solving

Organizational Skills

Leadership

Computer Literacy

Education

Registered Nurse or Licensed Clinical Social Worker

Bachelor's in Nursing or Certified Professional in Healthcare Quality (CPHQ)

Tools

Microsoft Word

Microsoft Excel

Job description

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

Ensures compliance with contract requirements for clinical quality management (CQM) to ensure quality care for Veterans. Identifies and evaluates potential quality issues and prepares summaries for further review and analysis. Supports activities of peer review and quality and safety committees. Reviews discharge summaries and consultation reports for compliance with clinical quality and contract requirements.

Education & Experience

Required:
o Registered Nurse or Licensed Clinical Social Worker, with current unrestricted license in appropriate state or territory of the United States o 3 years clinical experience (medical/surgical or behavioral health)

Preferred:
o Bachelor's in Nursing or Certified Professional in Healthcare Quality (CPHQ) o 1 or more years team lead or supervisory experience o 1 year experience in Quality Management o 1 year experience with data analysis and reporting o Experience with InterQual or similar criteria sets o General knowledge of Medicare, Veterans Administration, or other government health care programs

Key Responsibilities

o Identifies Potential Quality Issues (PQIs) by performing a timely review of medical documentation. This includes researching, investigating, analyzing, and preparing case summaries with appropriate recommendations for further actions.
o Develops peer review cases and other quality improvement activities for monitoring deviations from accepted standards of care and suggesting corrective action plans.
o Reviews Practice Pattern Analyses to assist with identifying physician practice patterns for confirmed severity cases.
o Collaborates with VA for data collection, reporting, and analysis of quality issues and contract compliance.
o Participates on safety and quality committees and peer review committees.
o Reviews Potential Quality Issues with Chief Medical Officer when appropriate.
o Provides support for the VA Clinical Quality committee meetings through case summary and report preparation.
o Provides supervisory/team lead support for Complex Authorization Specialists.
o Performs other duties as assigned.
o Regular and reliable attendance is required.

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.

Leadership: Provide clear direction and effective coaching.

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

Working Conditions

Working Conditions:
o Works within a standard office environment, with minimal travel
o Ability to lift 20 pounds
o Security clearance as required by contract

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.

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

TriWest job postings typically include a salary range, which can vary based on the specific role and location, butgenerally this position ranges from around $85,000 to $90,000 per year.

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. 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.