Utilization Management Clinical Reviewer

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. #J-18808-Ljbffr TriWest Healthcare Alliance