TriWest Healthcare Alliance · 1 month ago
Utilization Clinical Reviewer
United States
Full-time
Remote
Entry, Mid Level
$86K/yr - $95K/yr
2+ years expTriWest Healthcare Alliance is dedicated to serving America’s heroes by connecting them to healthcare in the community. The Utilization Clinical Reviewer will review and make decisions regarding the appropriateness and level of beneficiary care, applying clinical knowledge to ensure cost-effective care and proper utilization of resources.
Health Care
No H1B
Security Clearance RequiredU.S. Citizen Only
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
Qualification
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
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
Company
TriWest Healthcare Alliance
TriWest Healthcare Alliance - Serving Those Who Serve. At TriWest, we honor the sacrifice and service of our nations military families by
1001-5000 employees
Funding
Current Stage
Late StageTotal Funding
unknown2025-01-30Debt Financing
Leadership Team
Mark E. Babbitt
Senior Advisor to President & CEO
Joseph Oddo
Vice President and Chief Information Officer
Recent News
EIN Presswire
2025-07-22
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