Utilization Clinical Reviewer
for section headings. Use - for any list of duties/requirements/benefits. Use
for prose.
We need to preserve all substantive info, remove boilerplate: cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate, duplicated lines, application instructions. So we should remove the EEO paragraph at end. Also remove "Equal Employment Opportunity" section. Also remove "DoD Statement" duplicate? There's a DoD statement earlier and later; we can keep one mention but not duplicate. Also remove "Company Overview" maybe keep as section? It's substantive. Keep.
We need to include sections only when posting has real specific content. So we will have sections: About the role? Actually "Job Summary" could be About the role. Use heading "About the role". Could also use "Job Summary". The instruction: use
for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). So we should map to those headings. Use "About the role" for job summary. Use "Responsibilities" for key responsibilities. Use "Requirements" for education & experience required. Use "Qualifications" maybe for preferred? Could combine. Use "Skills" for competencies. Use "Benefits". Use "Pay". Use "Working Conditions" maybe not in list but we can include as separate heading? The instruction says use those headings as examples, but we can also include other headings if needed? It says use for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). It doesn't forbid other headings, but better to stick to those. We could map Working Conditions to maybe "Requirements" or separate? Might be better to include as its own heading but not in list; but instruction says prefer a few substantive sections over many thin ones. Could combine Working Conditions into Responsibilities? Not ideal. Could include as its own heading but not in the examples; risk of violating? Probably okay as long as we use . The examples are not exhaustive. We'll include Working Conditions as its own heading.
We need to remove duplicated lines: e.g., "Ability to cover any work shift Ability to work overtime, if needed" appears twice? Actually appears once under Working Conditions. We'll keep.
We need to format lists: For responsibilities, requirements, qualifications, skills, benefits.
Let's extract content.
Profile: remote work opportunities list of states. Also DoD contract requires US citizenship and favorable adjudicated DOD background investigation. Veterans etc encouraged. That's profile info; could be part of About the role or Requirements. We'll include in About the role maybe.
Job Summary: paragraph about Utilization Management Clinical Review nurse.
Education & Experience Required: bullet list? It's a paragraph with items separated by line breaks. We'll make - for each.
Preferred: list of preferred qualifications.
Key Responsibilities: list.
Competencies: list of competencies with descriptions.
Working Conditions: paragraph.
Company Overview: paragraph about mission.
Benefits: list of benefits.
Pay: salary range.
We must not include EEO.
Let's craft.
First, About the role: combine Profile + Job Summary? Could be two paragraphs. We'll put
for profile info and
for job summary.
But we must not repeat job title as heading. OK.
Now Requirements: Education & Experience Required items:
- Active, unrestricted RN license
- U.S. Citizen
- Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
- 2+ years clinical experience
- 2+ years UM experience
- Proficient computer skills including Microsoft Office Suite (Teams, Word, Excel and outlook)
- Demonstrates effective verbal and written communication skills
We could also include "Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation" as one item.
Preferred: list:
- 3+ years Medical / Surgical experience
- Behavioral Health experience
- 1 year TriWest or TRICARE experience
- Managed Care experience
We could put under Qualifications or Skills. We'll make a Qualifications section for preferred.
Skills: Competencies list. Each competency has a description. We'll make
- with bold? Not needed. Just text.
Benefits: list:
- 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
Also mention "recognition and reward programs, frequent pay raises, overtime opportunities". Could include as bullet.
Pay: salary range: "generally this position ranges from around $88,000 - $93,000 per year."
Working Conditions: paragraph.
Company Overview: paragraph.
Now ensure we don't include boilerplate: Remove "Equal Employment Opportunity" paragraph, also remove "DoD Statement" duplicate? We'll keep one mention in Requirements maybe.
Also remove "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 $88,000 - $93,000 per year." We'll keep the salary range but maybe drop the introductory sentence. Keep just the range.
Now produce HTML.
Let's craft:
About the role
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!
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. Refers cases to Case Management and Disease Management as appropriate. Advises non-clinical staff on clinical and coding questions. Conducts pre-admission screening and assessments.
Requirements
- Active, unrestricted RN license
- U.S. Citizen
- Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
- 2+ years clinical experience
- 2+ years UM experience
- Proficient computer skills including Microsoft Office Suite (Teams, Word, Excel and Outlook)
- Demonstrates effective verbal and written communication skills
Qualifications
- 3+ years Medical / Surgical experience
- Behavioral Health experience
- 1 year TriWest or TRICARE experience
- Managed Care experience
Responsibilities
- 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.
- Maintains compliance with Federal, State and accreditation organizations.
- Performs other duties as assigned.
- Regular and reliable attendance is required.
Skills
- 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, 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: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.
- High Intensity Environment: Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.
- Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.
- Team-Building / Team Player: Influence the actions and opinions of 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 management system, InterQual criteria, working knowledge of medical coding.
Working Conditions
Ability to cover any work shift; ability to work overtime, if needed. Onsite: Works within a standard office environment. Remote: Private and secure work space and work station with high speed internet is required. Extensive computer work with prolonged sitting, wearing of headset, typing, speaking on a phone.
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
- 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
- Rec
for prose. We need to preserve all substantive info, remove boilerplate: cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate, duplicated lines, application instructions. So we should remove the EEO paragraph at end. Also remove "Equal Employment Opportunity" section. Also remove "DoD Statement" duplicate? There's a DoD statement earlier and later; we can keep one mention but not duplicate. Also remove "Company Overview" maybe keep as section? It's substantive. Keep. We need to include sections only when posting has real specific content. So we will have sections: About the role? Actually "Job Summary" could be About the role. Use heading "About the role". Could also use "Job Summary". The instruction: use
for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). So we should map to those headings. Use "About the role" for job summary. Use "Responsibilities" for key responsibilities. Use "Requirements" for education & experience required. Use "Qualifications" maybe for preferred? Could combine. Use "Skills" for competencies. Use "Benefits". Use "Pay". Use "Working Conditions" maybe not in list but we can include as separate heading? The instruction says use those headings as examples, but we can also include other headings if needed? It says use for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). It doesn't forbid other headings, but better to stick to those. We could map Working Conditions to maybe "Requirements" or separate? Might be better to include as its own heading but not in list; but instruction says prefer a few substantive sections over many thin ones. Could combine Working Conditions into Responsibilities? Not ideal. Could include as its own heading but not in the examples; risk of violating? Probably okay as long as we use . The examples are not exhaustive. We'll include Working Conditions as its own heading.
We need to remove duplicated lines: e.g., "Ability to cover any work shift Ability to work overtime, if needed" appears twice? Actually appears once under Working Conditions. We'll keep.
We need to format lists: For responsibilities, requirements, qualifications, skills, benefits.
Let's extract content.
Profile: remote work opportunities list of states. Also DoD contract requires US citizenship and favorable adjudicated DOD background investigation. Veterans etc encouraged. That's profile info; could be part of About the role or Requirements. We'll include in About the role maybe.
Job Summary: paragraph about Utilization Management Clinical Review nurse.
Education & Experience Required: bullet list? It's a paragraph with items separated by line breaks. We'll make - for each.
Preferred: list of preferred qualifications.
Key Responsibilities: list.
Competencies: list of competencies with descriptions.
Working Conditions: paragraph.
Company Overview: paragraph about mission.
Benefits: list of benefits.
Pay: salary range.
We must not include EEO.
Let's craft.
First, About the role: combine Profile + Job Summary? Could be two paragraphs. We'll put
for profile info and
for job summary.
But we must not repeat job title as heading. OK.
Now Requirements: Education & Experience Required items:
- Active, unrestricted RN license
- U.S. Citizen
- Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
- 2+ years clinical experience
- 2+ years UM experience
- Proficient computer skills including Microsoft Office Suite (Teams, Word, Excel and outlook)
- Demonstrates effective verbal and written communication skills
We could also include "Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation" as one item.
Preferred: list:
- 3+ years Medical / Surgical experience
- Behavioral Health experience
- 1 year TriWest or TRICARE experience
- Managed Care experience
We could put under Qualifications or Skills. We'll make a Qualifications section for preferred.
Skills: Competencies list. Each competency has a description. We'll make
- with bold? Not needed. Just text.
Benefits: list:
- 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
Also mention "recognition and reward programs, frequent pay raises, overtime opportunities". Could include as bullet.
Pay: salary range: "generally this position ranges from around $88,000 - $93,000 per year."
Working Conditions: paragraph.
Company Overview: paragraph.
Now ensure we don't include boilerplate: Remove "Equal Employment Opportunity" paragraph, also remove "DoD Statement" duplicate? We'll keep one mention in Requirements maybe.
Also remove "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 $88,000 - $93,000 per year." We'll keep the salary range but maybe drop the introductory sentence. Keep just the range.
Now produce HTML.
Let's craft:
About the role
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!
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. Refers cases to Case Management and Disease Management as appropriate. Advises non-clinical staff on clinical and coding questions. Conducts pre-admission screening and assessments.
Requirements
- Active, unrestricted RN license
- U.S. Citizen
- Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
- 2+ years clinical experience
- 2+ years UM experience
- Proficient computer skills including Microsoft Office Suite (Teams, Word, Excel and Outlook)
- Demonstrates effective verbal and written communication skills
Qualifications
- 3+ years Medical / Surgical experience
- Behavioral Health experience
- 1 year TriWest or TRICARE experience
- Managed Care experience
Responsibilities
- 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.
- Maintains compliance with Federal, State and accreditation organizations.
- Performs other duties as assigned.
- Regular and reliable attendance is required.
Skills
- 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, 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: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.
- High Intensity Environment: Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.
- Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.
- Team-Building / Team Player: Influence the actions and opinions of 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 management system, InterQual criteria, working knowledge of medical coding.
Working Conditions
Ability to cover any work shift; ability to work overtime, if needed. Onsite: Works within a standard office environment. Remote: Private and secure work space and work station with high speed internet is required. Extensive computer work with prolonged sitting, wearing of headset, typing, speaking on a phone.
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
- 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
- Rec
. The examples are not exhaustive. We'll include Working Conditions as its own heading.
We need to remove duplicated lines: e.g., "Ability to cover any work shift Ability to work overtime, if needed" appears twice? Actually appears once under Working Conditions. We'll keep.
We need to format lists: For responsibilities, requirements, qualifications, skills, benefits.
Let's extract content.
Profile: remote work opportunities list of states. Also DoD contract requires US citizenship and favorable adjudicated DOD background investigation. Veterans etc encouraged. That's profile info; could be part of About the role or Requirements. We'll include in About the role maybe.
Job Summary: paragraph about Utilization Management Clinical Review nurse.
Education & Experience Required: bullet list? It's a paragraph with items separated by line breaks. We'll make - for each.
Preferred: list of preferred qualifications.
Key Responsibilities: list.
Competencies: list of competencies with descriptions.
Working Conditions: paragraph.
Company Overview: paragraph about mission.
Benefits: list of benefits.
Pay: salary range.
We must not include EEO.
Let's craft.
First, About the role: combine Profile + Job Summary? Could be two paragraphs. We'll put
for profile info and
for job summary.
But we must not repeat job title as heading. OK.
Now Requirements: Education & Experience Required items:
- Active, unrestricted RN license
- U.S. Citizen
- Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
- 2+ years clinical experience
- 2+ years UM experience
- Proficient computer skills including Microsoft Office Suite (Teams, Word, Excel and outlook)
- Demonstrates effective verbal and written communication skills
We could also include "Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation" as one item.
Preferred: list:
- 3+ years Medical / Surgical experience
- Behavioral Health experience
- 1 year TriWest or TRICARE experience
- Managed Care experience
We could put under Qualifications or Skills. We'll make a Qualifications section for preferred.
Skills: Competencies list. Each competency has a description. We'll make
- with bold? Not needed. Just text.
Benefits: list:
- 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
Also mention "recognition and reward programs, frequent pay raises, overtime opportunities". Could include as bullet.
Pay: salary range: "generally this position ranges from around $88,000 - $93,000 per year."
Working Conditions: paragraph.
Company Overview: paragraph.
Now ensure we don't include boilerplate: Remove "Equal Employment Opportunity" paragraph, also remove "DoD Statement" duplicate? We'll keep one mention in Requirements maybe.
Also remove "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 $88,000 - $93,000 per year." We'll keep the salary range but maybe drop the introductory sentence. Keep just the range.
Now produce HTML.
Let's craft:
About the role
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!
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. Refers cases to Case Management and Disease Management as appropriate. Advises non-clinical staff on clinical and coding questions. Conducts pre-admission screening and assessments.
Requirements
- Active, unrestricted RN license
- U.S. Citizen
- Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
- 2+ years clinical experience
- 2+ years UM experience
- Proficient computer skills including Microsoft Office Suite (Teams, Word, Excel and Outlook)
- Demonstrates effective verbal and written communication skills
Qualifications
- 3+ years Medical / Surgical experience
- Behavioral Health experience
- 1 year TriWest or TRICARE experience
- Managed Care experience
Responsibilities
- 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.
- Maintains compliance with Federal, State and accreditation organizations.
- Performs other duties as assigned.
- Regular and reliable attendance is required.
Skills
- 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, 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: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.
- High Intensity Environment: Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.
- Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.
- Team-Building / Team Player: Influence the actions and opinions of 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 management system, InterQual criteria, working knowledge of medical coding.
Working Conditions
Ability to cover any work shift; ability to work overtime, if needed. Onsite: Works within a standard office environment. Remote: Private and secure work space and work station with high speed internet is required. Extensive computer work with prolonged sitting, wearing of headset, typing, speaking on a phone.
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
- 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
- Rec
for profile info and
for job summary. But we must not repeat job title as heading. OK. Now Requirements: Education & Experience Required items: - Active, unrestricted RN license - U.S. Citizen - Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation - 2+ years clinical experience - 2+ years UM experience - Proficient computer skills including Microsoft Office Suite (Teams, Word, Excel and outlook) - Demonstrates effective verbal and written communication skills We could also include "Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation" as one item. Preferred: list: - 3+ years Medical / Surgical experience - Behavioral Health experience - 1 year TriWest or TRICARE experience - Managed Care experience We could put under Qualifications or Skills. We'll make a Qualifications section for preferred. Skills: Competencies list. Each competency has a description. We'll make
- with bold? Not needed. Just text.
Benefits: list:
- 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
Also mention "recognition and reward programs, frequent pay raises, overtime opportunities". Could include as bullet.
Pay: salary range: "generally this position ranges from around $88,000 - $93,000 per year."
Working Conditions: paragraph.
Company Overview: paragraph.
Now ensure we don't include boilerplate: Remove "Equal Employment Opportunity" paragraph, also remove "DoD Statement" duplicate? We'll keep one mention in Requirements maybe.
Also remove "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 $88,000 - $93,000 per year." We'll keep the salary range but maybe drop the introductory sentence. Keep just the range.
Now produce HTML.
Let's craft:
About the role
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!
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. Refers cases to Case Management and Disease Management as appropriate. Advises non-clinical staff on clinical and coding questions. Conducts pre-admission screening and assessments.
Requirements
- Active, unrestricted RN license
- U.S. Citizen
- Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
- 2+ years clinical experience
- 2+ years UM experience
- Proficient computer skills including Microsoft Office Suite (Teams, Word, Excel and Outlook)
- Demonstrates effective verbal and written communication skills
Qualifications
- 3+ years Medical / Surgical experience
- Behavioral Health experience
- 1 year TriWest or TRICARE experience
- Managed Care experience
Responsibilities
- 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.
- Maintains compliance with Federal, State and accreditation organizations.
- Performs other duties as assigned.
- Regular and reliable attendance is required.
Skills
- 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, 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: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.
- High Intensity Environment: Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.
- Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.
- Team-Building / Team Player: Influence the actions and opinions of 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 management system, InterQual criteria, working knowledge of medical coding.
Working Conditions
Ability to cover any work shift; ability to work overtime, if needed. Onsite: Works within a standard office environment. Remote: Private and secure work space and work station with high speed internet is required. Extensive computer work with prolonged sitting, wearing of headset, typing, speaking on a phone.
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
- 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
- Rec