Utilization Management Clinical Reviewer

TriWest Healthcare Alliance; Phoenix (AZ); Hybrid; USD 88,000 - 93,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

401(k) with matching

Disability & life insurance

Job summary

TriWest Healthcare Alliance seeks an experienced Utilization Management Clinical Review nurse to determine medical necessity for preauthorization, inpatient and continued stay reviews in Behavioral Health and Medical/Surgical cases.

You will apply InterQual criteria and document findings for Medical Director review. Remote work opportunities are available nationwide.

Qualifications

• Active, unrestricted RN license.
• U.S. Citizen.
• Ability to receive a favorable interim and adjudicated final DOD background investigation.
• 2+ years of clinical experience.
• 2+ years of utilization management experience.
• Proficient computer skills including Microsoft Office (Teams, Word, Excel, Outlook).
• Effective verbal and written communication skills.

Responsibilities

• Conduct prior authorization, continued stay, and referral management activities.
• Assess medical necessity by screening information against InterQual criteria, policy keys, and Behavioral Health criteria.
• Interpret information and determine alignment with TriWest benefit program.
• Ensure timely reviews for requesting facilities and notify parties appropriately.
• Refer cases to Case Management, Care Coordination, or Disease Management for review when necessary.
• Prepare cases for Medical Director and Peer Review according to policy.

Skills

Verbal communication

Written communication

Microsoft Office

Tools

Microsoft Office Suite

Job description

Profile

Remote work opportunities are available in the following states: 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.

Our Department of Defense contract requires U.S. citizenship and a favorably adjudicated DOD background investigation. 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 to provide cost‑effective care and ensure proper utilization of resources. Applies clinical knowledge to determine medical necessity for preauthorization, inpatient, and continued stay reviews for Behavioral Health and Medical/Surgical requests. Utilizes clinical criteria and policy keys to complete reviews, documents in the medical management information system, prepares and presents more complex cases for Medical Director review, refers cases to Case Management and Disease Management as needed, advises non‑clinical staff on clinical and coding questions, and conducts pre‑admission screening and assessments.

Education & Experience

Required:

• Active, unrestricted RN license
• U.S. Citizen
• Ability to receive a favorable interim and adjudicated final DOD background investigation
• 2+ years of clinical experience
• 2+ years of utilization management experience
• Proficient computer skills including Microsoft Office (Teams, Word, Excel, Outlook)
• Effective verbal and written communication skills

Preferred:

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

Key Responsibilities

• Conduct prior authorization, continued stay, and referral management activities
• Assess medical necessity by screening available information against established criteria using InterQual Clinical Guidelines, policy keys, and Behavioral Health criteria
• Interpret information and decide whether authorizations align with the TriWest benefit program
• Ensure timely reviews for requesting facilities and appropriate notification to parties
• Contact beneficiaries and/or providers to obtain or clarify medical information as needed
• Refer cases to Case Management, Care Coordination, or Disease Management for review when necessary
• Prepare cases for Medical Director and Peer Review according to established policyFlag potential quality issues and complaints to Clinical Quality Management
• Notify the Internal Audit & Corporate Compliance departments of cases requiring potential fraud review
• Maintain compliance with federal, state, and accreditation organizations
• Perform other duties as assigned
• Maintain regular and reliable attendance

Competencies

• Communication / People Skills: Ability to influence or persuade others; adapt to different styles; listen critically; collaborate
• Computer Literacy: Ability to function in a multi‑system Microsoft environment, including Word, Outlook, TriWest Intranet, the Internet, and department software applications
• Coping / Flexibility: Resiliency in adapting to a variety of situations while maintaining a sense of purpose and mature problem‑solving approach
• Empathy / Customer Service: Customer‑focused behavior; listening skills, patience, respect, empathy for another’s position
• Independent Thinking / Self‑Initiative: Ability to organize tasks, adjust to priorities, learn systems within time constraints and available resources; detail‑oriented
• High Intensity Environment: Ability to function in a fast‑paced environment with multiple simultaneous activities while maintaining focus and workflow control
• Organizational Skills: Ability to organize tasks, adjust to priorities, learn systems within time constraints and available resources; detail‑oriented
• Team‑Building / Team Player: Influence 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 coding, medical management systems, InterQual criteria, and working knowledge of medical coding

Working Conditions

• Ability to cover any work shift
• Ability to work overtime if needed
• On‑site: Works within a standard office environment
• Remote: Requires a private and secure workspace with high‑speed Internet
• Extensive computer work, prolonged sitting, wearing a headset, typing, and speaking on the phone

Benefits

• Medical, Dental, and Vision Coverage
• 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

Salary range: approximately $88,000 – $93,000 per year.

Equal Employment Opportunity

TriWest Healthcare Alliance is an equal employment opportunity employer. We are proud to have an inclusive work environment and believe a diverse team is a strength that drives our success. Candidates are considered for positions based on merit and without discrimination on 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.