Manager, Retrospective UM

We offer remote work opportunities (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 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 Reporting to the Director of Utilization Management, this position manages retrospective Utilization Management (UM) programs and staff that support Medical Claims Review, Pricing and Coding, Focused Studies, and DRG Validation reviews. The Manager develops, implements, and oversees UM program components to optimize UM strategies, goals, policies and procedures to ensure compliance with contract and accreditation standards. Education & Experience Required: Bachelor’s degree in Nursing, Health Administration, health-related field or equivalent education and experience. Current, unrestricted Registered Nurse license or equivalent. 4+ years’ experience in a Health Care Administration, Medical/Surgical or Behavioral Health UM and/or medical claims environment. 3 years supervisory or management leadership experience in a healthcare environment. Preferred: Commercial Managed Care in UM or medical claims experience. Master's Degree in Nursing or related field. Experience with TRICARE policy and programs. Experience with policy development and technical writing. Key Responsibilities Direct operational leadership of Utilization Management Retrospective process functions and staff to ensure compliance with contract requirements and adherence to contract deliverables. Monitor day‑to‑day operations of the Utilization Management Retrospective team to identify barriers to meeting contract or accreditation requirements. Systematically evaluate the quality and effectiveness of staff performance, analyzing appropriate data and information to identify areas of improvement; advise and coach when appropriate and complete annual performance appraisals. Manage activities necessary to ensure appropriate utilization of resources while maintaining optimal achievable standards of care. Supervise staff to include interviewing and hiring; planning and implementing orientation and training strategies for new‑hire employees; setting and managing expectations, coaching and ensuring team and individual goals are met. Ensure adherence to accreditation standards, contract policy, contractual requirements, and nationally recognized practice standards. Participate in development of desk procedures, education, and auditing to support uniform application of programs and compliance with program policy and standards. Oversee the quality assurance and quality improvement processes related to retrospective UM, including medical claims processing, pricing and coding, focused studies, and DRG Validation programs. Ongoing collaboration with Claims Administration and Claims Processing leadership to maintain consistent and accurate retrospective UM processing outcomes. Participate in cross‑functional teams for corporate projects. Perform other duties as assigned. Regular and reliable attendance is required. Coaching / Training / Mentoring: Actively foster actions required for desired business outcomes through ongoing constructive feedback. 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. Delegation Skills: Provide clear performance expectations for projects and ensure adequate access to resources for completion. Information Management: Ability to manage large amounts of complex information easily, communicate clearly, and draw sound conclusions. Leadership: Successfully manage different styles of employees; provide clear direction and effective coaching. Organizational Skills: Ability to organize people or tasks, adjust to priorities, and learn systems, within time constraints and with available resources; detail‑oriented. Problem Solving / Analysis: Ability to solve problems through systematic analysis of processes with sound judgment; have a realistic understanding of relevant issues. Team‑Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment. Technical Skills: Knowledge of TRICARE program and benefits; customer service, quality assurance, and UM program metrics; legal, regulatory requirements and HIPAA privacy regulations; advanced knowledge of grievances and appeal processes; collaboration skills. Proficient with the Microsoft Office suite of applications. Working Conditions Remote/virtual environment if preferred. Regular and reliable attendance is required. Availability to cover any work shift. Ability to travel as needed. Extensive computer work with long periods of sitting. Department of Defense security clearance required. Benefits include: 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 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 supports diversity at every organizational level, and we highly encourage candidates from all backgrounds to apply. Applicants are considered for positions based on merit and 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. #J-18808-Ljbffr