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

Responsible for system-wide development, implementation, evaluation and management of the staff associated with the Case Management Programs that support the T-5 TRICARE West Region Contract. Under the direction of the Vice President of T5 Clinical Operations, this position will have the responsibility to develop clinical program components to optimize Case Management and Care Coordination strategies and goals, and develop and implement policies and procedures to ensure compliance with URAC accreditation standards and develops training aides to support policies. This position also oversees Case Management and Care Coordination quality improvement projects and auditing for performance management and improvement.

Education & Experience

Required:
o Current, unrestricted Registered Nurse (RN) license recognized as valid by the applicable state licensure board where the position is located

o Bachelor's Degree in Nursing, Health Care Administration or other health related field

o URAC recognized Case Manager Certification

o Minimum of five (5) years clinical experience

o Minimum of five (5) years progressively responsible management experience

o Minimum of five (5) years experience in Case Management and program development

Preferred:
o Previous experience as a director of case management

o Government or commercial managed care experience

o Demonstrated experience in performing analysis of utilization and quality data

o Knowledge of government health care programs, TRICARE or Medicare/Medicaid

Key Responsibilities

o Direct the overall operational leadership of Case Management and Care Coordination functions and staff to ensure compliance with contract requirements and adherence to contract deliverables.

o Performs clinical program analyses to establish program impact, identify opportunities for improvement and recommend strategies to achieve goals and performance targets.

o Work with executive leadership to ensure targets are met for the annual operating plan/financial management.

o Performs annual and ongoing evaluation of the CM programs to ensure adherence to URAC standards, TRICARE policy, contractual requirements, HIPAA privacy and nationally recognized practice standards.

o Serves as designated Point of Contact to the TRICARE Regional Office West (TROW) on matters related to CM processes and contractual requirements.

o Develops desk procedures, education and auditing to support uniform application of programs and compliance with program policy and standards.

o Directs the design of data collection tools, reports and administrative protocols for CM program performance management and contract reporting.

o Directs and administers TRICARE Specialty Programs, demonstrations, and benefits to beneficiaries.

o Coordinate with Medical Director to educate and communicate expectations with providers.

o Collaborates with network providers, Military Treatment Facilities and TRICARE Regional Office West regarding CM program initiatives and responds to requests for assistance for program information or data.

o Performs other duties as assigned. o Regular and reliable attendance is required.

Competencies

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

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.

Empathy / Customer Service: Customer-focused behavior; Helping approach, including listening skills, patience, respect, and empathy for another's position.

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.

Leadership: Successfully manage different styles of employees; Provide clear direction and effective coaching.

Multi-Tasking / Time Management: Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environment.

Organizational Skills: Ability to organize people or tasks, adjust to priorities, 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; Has 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 programs and benefits, Managed Care, and healthcare principles and delivery systems, Knowledge of CMSA, URAC national best-practice standards; Case management interventions, Psychosocial and Support Systems, crisis intervention strategies, collaboration skills, legal and regulatory requirements, HIPAA privacy regulations, Medicaid and Medicare eligibility requirements and benefits, prospective payment methodologies, and Health Care Reimbursement; Working knowledge of worker compensation principles; Proficient with ACCESS, Excel, and PowerPoint.

Working Conditions

Working Conditions:
o Availability to work non-regular hours as required

o Works within a standard office environment, with travel to other office locations

o Extensive computer work with long periods of 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.

DoD Statement

Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.

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
• 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

TriWest job postings typically include a salary range, which can vary based on the specific role and location, but generally this position ranges from around $140, 000 - $171, 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 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.