Utilization Clinical Reviewer

TriWest Healthcare Alliance; Phoenix (AZ); Remote; USD 60,000 - 90,000; Full time

Job summary

TriWest Healthcare Alliance is seeking a Utilization Clinical Reviewer to focus on assessing medical necessity and managing benefits for healthcare services. The ideal candidate will possess an active RN license, relevant clinical experience, and strong communication skills. This role involves reviewing cases and ensuring appropriate utilization of resources, with a commitment to serving veterans and military families.

Benefits

Medical, Dental and Vision Coverage

Generous paid time off

401(k) Retirement Savings Plan (with matching)

Tuition reimbursement

Paid volunteer time

Qualifications

• Must have 2+ years clinical and UM experience.
• Active RN license is required.
• Demonstrates effective written and verbal communication skills.

Responsibilities

• Conducts prior authorization and referral management.
• Assesses medical necessity using established criteria.
• Documents and prepares complex cases for review.

Skills

Effective verbal and written communication

Clinical knowledge

Computer literacy

Organizational skills

Customer-focused behavior

Education

Active, unrestricted RN license

Various preferred experiences (Medical/Surgical, UM)

Tools

Microsoft Office Suite

Clinical management systems knowledge

Job description

Join to apply for the Utilization Clinical Reviewer role at TriWest Healthcare Alliance

18 hours ago Be among the first 25 applicants

Join to apply for the Utilization Clinical Reviewer role at TriWest Healthcare Alliance

Profile

We offer remote work opportunities (AK, AR, AZ, CA, *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

The Utilization Management Clinical Review nurse reviews and makes decisions about the appropriateness and level of beneficiary care being provided in an effort to provide cost effective care and ensure proper utilization of resources. Applies clinical knowledge to make determinations for preauthorization, inpatient and continued stay reviews for Behavioral Health and Medical/Surgical requests to establish medical necessity, benefit coverage, appropriateness of quality of care, and length of stay or care plan. Utilizes clinical criteria and policy keys to complete review. Documents in the medical management information system. Prepares and presents more complex cases for Medical Director Review. Refer cases to Case Management and Disease Management as appropriate. Advises non-clinical staff on clinical and coding questions. Conducts pre-admission screening and assessments.

Education & Experience

Required:

• Active, unrestricted RN license
• U.S. Citizen
• Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
• 2+ years clinical experience
• 2+ years UM experience
• Proficient computer skills including Microsoft Office Suite (Teams, Word, Excel and outlook)
• Demonstrates effective verbal and written communication skills
  
  

Preferred

• 3+ years Medical / Surgical experience
• Behavioral Health experience
• 1 year TriWest or TRICARE experience
• Managed Care experience
  
  

Key Responsibilities

• Conducts prior authorization, continued stay, and referral management activities.
• Assesses medical necessity by screening available information against established criteria, using InterQual Clinical Guidelines Policy Keys and Behavioral Health criteria.
• Interprets information and makes decision whether authorizations align with the TriWest benefit program.
• Ensures timely reviews for requesting facilities and appropriate notification to parties.
• Contacts beneficiary and / or provider to obtain or clarify medical information as necessary.
• Refers cases to Case Management, Care Coordination, or Disease Management for review as necessary.
• Prepares cases for Medical Director and Peer Review according to established policy.
• Refers potential quality issues and complaints to Clinical Quality Management.
• Notifies Internal Audit & Corporate Compliance department of cases for review of potential fraud.
• Maintain compliance with Federal, State and accreditation organizations.
• Performs other duties as assigned.
• Regular and reliable attendance is required.
  
  

Competencies

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.

Empathy / Customer Service: Customer-focused behavior; Helping approach, including listening skills, patience, respect, and empathy for another's position.

Independent Thinking / Self-Initiative: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.

High Intensity Environment: Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.

Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented

Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment

Technical Skills: Knowledge of TRICARE policies and procedures, Utilization Management principles, Managed Care concepts, medical terminology, medical management system, InterQual criteria, working knowledge of medical coding

Working Conditions

Working Conditions

• Ability to cover any work shift
• 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
  
  

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.

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
  
  

*Annual base salary for Colorado, Hawaii, Illinois, Minnesota, Washington D.C. and Washington State residents: $81,000 - $103,000 depending on experience*

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 cultivates and supports diversity at every organizational level, including hiring and retaining a diverse workforce, and we highly encourages candidates from all backgrounds to apply. Applicants are considered for positions 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.

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Research, Analyst, and Information Technology

• Industries

  Hospitals and Health Care

Referrals increase your chances of interviewing at TriWest Healthcare Alliance by 2x

Get notified about new Clinical Reviewer jobs in Phoenix, AZ.

Contracts Assistant - Healthcare (Remote)

Intake Patient Care Representative (REMOTE)

Crisis Counselor - Fully Remote in Arizona

Intake Patient Care Representative (REMOTE)

Crisis Counselor - Fully Remote in Arizona

Program Administrator (Healthcare referral capture) - Fully Remote

Phoenix, AZ $60,000.00-$75,000.00 1 week ago

Work From Home | Claim Representative | Flexible Hours

Intake Specialist (Care Management and Navigation)

REMOTE WORK FROM HOME/CLAIMS REPRESENTATIVE

Pharmacy Tech Support / Call Center Representative (Remote)

Freelance English Content Writer - AI Tutor

Medical Scribe (Hybrid/remote AZ Residents Only)

Contract Literacy Specialist (Southwest)

Default Loan Claims Analyst - 100% REMOTE

We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.