Utilization Clinical Reviewer

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. 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 being provided in an effort to provide cost effective care and ensure proper utilization of resources. Applies clinical knowledge to make determinations for preauthorization, inpatient and continued stay reviews for Behavioral Health and Medical/Surgical requests to establish medical necessity, benefit coverage, appropriateness of quality of care, and length of stay or care plan. Utilizes clinical criteria and policy keys to complete review. Documents in the medical management information system. Prepares and presents more complex cases for Medical Director Review. Refer cases to Case Management and Disease Management as appropriate. Advises non-clinical staff on clinical and coding questions. Conducts pre-admission screening and assessments.

Conducts prior authorization, continued stay, and referral management activities. Assesses medical necessity by screening available information against established criteria, using InterQual Clinical Guidelines Policy Keys and Behavioral Health criteria. Interprets information and makes decision whether authorizations align with the TriWest benefit program. Ensures timely reviews for requesting facilities and appropriate notification to parties. Contacts beneficiary and / or provider to obtain or clarify medical information as necessary. Refers cases to Case Management, Care Coordination, or Disease Management for review as necessary. Prepares cases for Medical Director and Peer Review according to established policy. Refers potential quality issues and complaints to Clinical Quality Management. Notifies Internal Audit & Corporate Compliance department of cases for review of potential fraud. Maintain compliance with Federal, State and accreditation organizations. Performs other duties as assigned. Regular and reliable attendance is required.