This is a hybrid position, m ostly remote, but onsite in Phoenix, AZ occasionally.

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

Manages Clinical Operations Regulatory Compliance, policy development, and program execution. This position reports to the VP Clinical Operations and coordinates with clinical operations leaders to assure URAC and T-5 Contract compliance. This position will have the responsibility to develop, implement and provide oversight of TriWest Clinical compliance program, ensuring adherence to all applicable federal, state and local regulations, as well as accreditation standards. This role focuses on maintaining the integrity of the clinical operations through robust policies, procedures, auditing and effective governance oversight.

Education & Experience

Required:

• Current, unrestricted Registered Nurse (RN) or Licensed Clinical Social Worker (LCSW) license recognized as valid by the applicable state licensure board where the position is located
• Bachelor's Degree in Nursing, Social Work, Health Care Administration or other health related field
• U.S. Citizen
• Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
• 5 years' experience quality, compliance or related field in healthcare
• 5 years' experience in management of staff and programs

Preferred:

• URAC (Utilization Review Accreditation Commission) recognized Case Manager Certification Master's Degree in Nursing or related field
• Previous experience leading and managing case management or utilization management Veterans Healthcare or TRICARE Program experience
• Demonstrated experience in performing analysis of utilization and quality data and with policy development and technical writing

Key Responsibilities

• Provides leadership to ensure compliance with URAC standards.
• Directs all aspects of URAC accreditation for relevant clinical programs.
• Supervises accreditation coordinators and collaborates subject matter experts related to accreditation compliance. Organizes and coordinates workflows with immediate team and related teams. Provides direction, coaching, performance management and issues resolution to team.
• Ensures ongoing compliance with all URAC standards, including continuous monitoring, gap analysis, implementation.
• Ensures comprehensive documentation for URAC accreditation, including policies, procedures, training records, and evidence of compliance.
• Provides oversight of Clinical Operations Policy and Procedure Development and management.
• Develops, reviews, revises and maintains all clinical operations policies and procedures to ensure compliance with regulatory requirements, URAC and internal best practice.
• Establishes a systematic process for policy review cycles, approvals, communication and version control.
• Designs, implements, and manages a comprehensive clinical auditing program to assess adherence to policies, procedures, regulatory requirements, and URAC standards.

• Conducts routine and ad hoc audits of clinical operations departments, provider credentialling, appeals and grievances related to clinical operations, and special oversight programs related to quality of care delivered in the network (e.g. prescription monitoring and TRICARE Quality Monitoring Contract or TQMC).
• Provides oversight and coordination of the clinical audit programs and performs analyses to measure program impact and identify opportunities to improve the effectiveness of the program to meet performance targets.
• Performs annual and ongoing evaluation of the Clinical programs to ensure adherence to URAC standards, TRICARE policy, contractual requirements, HIPAA privacy and nationally recognized practice.
• Develops training programs, training documents, and flow diagrams to address targeted operational issues related to compliance and audit.
• 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.

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, Excel, PowerPoint, Outlook, TriWest Intranet, the Internet, and department software applications.

Delegation Skills: Provide clear performance expectations for projects and ensure adequate access to resources for completion.

Independent Thinking / Self-Initiative: Critical thinker 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.

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.

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. Ability to plan, implement, and monitor program effectiveness and efficiency.

Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment.

Technical Skills: Thorough knowledge of TRICARE programs and benefits, URAC national best-practice standards; health care delivery; clinical quality assurance program metrics, utilization management, case management, managed care concepts, management reporting tools, and medical management systems; ability to perform critical, in-depth analysis of medical records for appropriateness and level-of-care determinations.

Working Conditions

• Works non-regular hours, as required
• Works hybrid, remotely and in office, with 10% travel
• Extensive computer work with prolonged sitting
• Department of Defense security clearance required

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
• 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 $109, 000 to $139, 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.