Clinical Reviewer - LPN (Finance)
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).
Veterans, Reservists, Guardsmen and military family members are encouraged to apply!
Job Summary
Applies clinical knowledge to make determinations for pre-authorizations of specific procedures and services to ensure adherence to contract benefits. Conducts Medical / Surgical medical necessity reviews. Compiles information needed to process prior authorization requests and 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:
• Licensed Practical Nurse or Licensed Vocational Nurse, with current unrestricted license in appropriate state or territory in the United States
• 2+ years' experience with Medical / Surgical
• U.S. Citizenship - if assigned to TRICARE contract
• Must be able to receive a favorable interim and adjudicated final Department of Defense (DoD) background investigation - if assigned to TRICARE contract
• Proficient working with on-line systems
Preferred:
• 5 years' experience with Medical / Surgical
• 1 year TriWest or TRICARE experience
• Managed Care experience
Key Responsibilities
• Conducts prior authorization activities and referral management activities.
• Assesses medical necessity by screening available information against established criteria, using InterQual Clinical Guidelines, Clinical Decision Support Tool, and Behavioral Health criteria. Interprets information and makes decision whether authorizations fits 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.
• 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 fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.
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.
Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment.
Technical Skills: Utilization Management principles, Managed Care concepts, medical terminology, medical management system, InterQual criteria, working knowledge of medical coding.
Working Conditions
Working Conditions:
• Availability to work any shift
• Works within a standard office environment, with minimal travel
• Extensive computer work with prolonged sitting
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
*Annual base salary for Colorado, Hawaii, Washington D.C. and Washington State residents: $58,000 - $74,000 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.
