Medical Claims Reviewer - RN (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!!

Must be a U.S. Citizen .

Job Summary

Conducts retrospective review of behavioral health or medical/surgical claims for inpatient and outpatient services to establish medical necessity, benefit coverage, appropriateness of quality of care, and/or length of stay or care plan. Applies clinical, coding and processing knowledge to conduct review and process claims. Compiles and review clinical information necessary to prepare cases Ensures adherence to program benefits as authorized. Provides clinical and coding-related information to medical director, providers, peer reviewers, Claims Administration, Program Integrity, Clinical Quality Management and the claims subcontractor as needed. Advises clinical and non-clinical staff on claims and coding questions.

Education & Experience

Required:

• Current, Active, unrestricted RN
• U.S. Citizen
• Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation.
• Minimum 2 years of Clinical experience in direct patient care (either medical or behavioral health)
• Minimum 2 years UM experience utilizing commercially developed UM criteria and/or experience processing medical claims

Preferred:

• 2+ years Managed Care
• 1+ year TriWest or TRICARE
• Current Procedural Terminology

Key Responsibilities

• Conducts medical claims review using current claims processing guidelines and established clinical criteria e.g. RADs, Interqual, and policy keys, to evaluate medical necessity, appropriateness of care and program benefits, exclusions and limitations.
• Prepares cases for medical director review as indicated.
• Validates all appropriate data is supplied with program invoice.
• Reviews claim data for process improvements related to all aspects of claims processing
• Ensures contract compliance for timelines regarding resolution of medical claims.
• Communicates effectively with management and peers.
• Consistently meets medical claims processing production and quality metrics.
• Identifies and reports any potential quality or fraud issues to management, Clinical Quality Management or Program Integrity as needed.
• Provides clinical and/or coding support regarding projects and/or questions. clinical and codingquestions.
• Performs other duties as assigned.
• Regular and reliable attendance is required.

Competencies

Coaching / Training / Mentoring: Actively foster actions required for desired business outcomes through ongoing constructive feedback.

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

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 TriWest 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.

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: Thorough knowledge of policies and procedures, Managed Care concepts and medical terminology. Proficient with claim and coding tools such as, RADS, Find-A-Code, Current Procedural Terminology, Health Care Financing Administration Common Procedure Coding System, and Current Dental Terminology. Ability to meet or exceed production standards in compliance with contract.

Working Conditions

• Availability to work any shift
• Ability to work independently from home
• 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 DC and Washington State residents: Average $95,579 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.