TriWest
Healthcare Alliance, headquartered in Phoenix,
Arizona, manages and administers quality healthcare
services for our nation's active and retired
uniformed military service members and their
families, through a contract with the Department
of Defense.
These individuals are eligible for the DoD's
regionally managed health care program for
the military, called TRICARE. TriWest manages
and administers TRICARE throughout the 21-state
TRICARE West Region.
Clinical Quality Reviewer
Ensures compliance with the program requirements
for Clinical Quality Management (CQM) within
TRICARE West Region to ensure quality care
for TRICARE beneficiaries, and investigates
medical records retrospectively for potential
quality and utilization issues, consistent
with URAC standards.
Education & Experience:
Required
• Registered Nurse with current unrestricted
license in appropriate state
• 3 years clinical experience (medical/surgical)
Preferred
• Bachelor's in Nursing or Certified Professional
in Healthcare Quality (CPHQ)
• 1 year experience in Quality Management
• 1 year experience with data analysis and
reporting
• Experience with InterQual criteria
• General knowledge of Medicare, TRICARE, or
other government health care programs
Key Responsibility Areas:
• Identifies Potential Quality Issues (PQIs)
by performing a timely review of the medical
records. This includes researching, investigating,
analyzing, and preparing case summaries with
appropriate recommendations for further actions.
• Develops peer review cases and other quality
improvement activities for monitoring deviations
from accepted standards of care and suggesting
corrective action plans.
• Responds to NQMC concerns,and documents a
rationale for cases when TriWest's position
does not concur with the NQMC's position.
• Requests Practice Pattern Analyses from a
Quality Management Specialist II (QMS II) to
assist with identifying physician practice
patterns for confirmed severity cases.
• Identifies and refers cases for focused reviews
to the Manager, Clinical Quality Management.
• Performs focused study data collection, reporting,
analysis, and makes recommendations for improvement.
• Refers cases for review as appropriate to
Program Integrity, Case Management, Population
Health Improvement, Congressional and Customer
Relations, and other TriWest departments.
• Participates on quality committees.
• Reviews Potential Quality Issues with Medical
Directors when appropriate
To view the posting and complete your on line
application, please visit our web site www.recruiter.triwest.com Posted on: August 9, 2010
TriWest
Healthcare Alliance, headquartered in North
Phoenix, manages and administers quality healthcare
services for our nation's active and retired
uniformed military service members and their
families, through a contract with the Department
of Defense.
These individuals are eligible for the DoD's
regionally managed health care program for
the military, called TRICARE. TriWest manages
and administers TRICARE throughout the 21-state
TRICARE West Region.
For more information about TriWest, please
explore our website at www.triwest.com.
Quality Management Supervisor
Supervises Quality Management staff in ensuring
compliance with the TRICARE Operations Manual
Chapter 7, Utilization and Quality Management,
requirements for the TRICARE West Region. Oversees
the review and reporting activity for the National
Quality Monitoring Contractor (NQMC). Assists
with multi-functional Peer Review Organization
(PRO) activities.
Education & Experience:
Required
• Registered Nurse, with current unrestricted
license
• 5+ years clinical experience in a variety
of settings
• 2+ years supervisory experience
• 1+ year experience in Quality Management
Preferred
• Bachelor's degree in Nursing
• CPHQ
• Experience with InterQual criteria
• Managed care experience
Key Responsibility Areas:
• Supervises Quality Management specialists:
daily operations and ensures timeliness and
accuracy of work to meet all contract requirements.
• Assigns cases appropriately according to
clinicians¿ scope of practice.
• Monitors and ensures appropriate and accurate
focused study data collection, analysis and
reporting.
• Develops and maintains training modules on
quality management basics for teaching staff.
• Trains and mentors Quality Management staff.
Conducts performance evaluations and develops
performance improvement plans as necessary.
• Identifies, develops, and monitors focused
reviews and other quality studies. Keeps manager
informed of issues related to quality studies.
Alerts Manager to case transfers.
• Provides accurate communications on
case reviews.
• Reviews medical records that
have been requested
by legal department within timelines and
flags appropriate documents.
• Develops monthly management report on staff
productivity and outcomes.
• Performs monthly staff audits and develops
summary reports.
• Facilitates working case review meetings.
• Conducts Potential Quality Issue (PQI)
investigations by performing a timely and
complete case analysis.
Maintains a consistent PQI caseload of 2
- 5 cases.
• Requests query reports as appropriate and
analyzes data supporting focused reviews
and quality studies.
• Refers cases for review as appropriate
to Program Integrity, Case Management, Provider
Services, Congressional and Customer Relations,
and other TriWest departments.
• Participates on TriWest committees as a
representative of Clinical Quality Management.
To view the posting and complete your on line
application, please visit our web site www.recruiter.triwest.com
Posted on: August 9, 2010
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