Applied Behavior Analysis - Quality Monitor Clinician

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.

We offer remote work opportunities (AK, AR, AZ, CA, *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. Veteran, Military Spouse or Military Affiliated are encouraged to apply! Reviews medical documentation and claims to ensure Applied Behavior Analysis (ABA) provider compliance with contract and program requirements for the Autism Care Demonstration (ACD) in the TRICARE West Region. The role helps to ensure quality care is delivered for TRICARE beneficiaries by identifying evaluating medical records and claims retrospectively for potential quality, safety, utilization, or billing issues by using organizational, national, and TRICARE standards for consistency. Supports activities of peer review and quality and safety committees.

Clinical review of ABA provider documentation to assess quality and adherence to program requirements. Identifies Potential Quality Issues (PQIs) by performing a timely review of the medical records. Identifies opportunities for provider education and accomplishes outreach to providers/groups with inconsistencies or errors identified. Assists the company with the initiation of progressively more severe administration action, commensurate with the seriousness of the identified problems Administrative review of ABA claims for detection and prevention of fraud and abuse to the TRICARE Program and beneficiaries, to include a review of suspect billing practices and document risks to determine improper payments in the ACD program. Identification and initiation of recoupments of claims dollars paid Develops peer review cases and other quality improvement activities for monitoring deviations from accepted standards of care and suggesting corrective action plans. Collaborate with Clinical Quality Management (CQM) on Practice Pattern Analyses if applicable. Identifies focused review topics to Clinical Quality Management Leadership. Performs focused study data collection, reporting, analysis, and makes recommendations for improvement. Refers cases for review as appropriate to Program Integrity, Case Management, Care Coordination, Population Health Improvement, Disease Management, Congressional Relations & Customer Grievances and other TriWest departments. Participates on quality committees. Reviews Potential Quality Issues with Medical Directors when appropriate. Performs other duties as assigned. Regular and reliable attendance is required.