Utilization Review Nurse Salary in Phoenix, AZ

Job Summary We offer remote work opportunities (AK, AR, AZ, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE,NV, NM, NC, ND, OK, OR, SC, SD, TX, UT, VA/DC, WI & WY only) This leader will report to the Manager of Case Management Special Programs under the overall Case Management program, specifically supporting TRICARE beneficiaries seeking benefits under Extended Care Health Option (ECHO) and Autism Care Demonstration (ACD). Supervises daily operations of case management special programs services and staff. **Veterans, Reservists, Guardsmen, and military family members are encouraged to apply** Education & ExperienceRequired: • Registered Nurse (RN) or Licensed Clinical Social Worker (LCSW), with a current unrestricted license, with one (1) year supervisory experience or equivalent leadership role • U.S. Citizenship • Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation, and o Three years full-time equivalent of direct clinical care to the consumer, and, o Two Years care coordination or case management experience. Preferred: • Experience in TRICARE ECHO and Autism Care Demonstration programs. • Bachelor's degree or higher in health-related field • Case Manager Certification by a URAC-recognized entity (e.g. ANCC, CCMC). If not currently certified, certification will be required within two (2) years of hire. Key Responsibilities• Supervises the daily operations of case management specialty program services. Hires, coaches, counsels, evaluates, and develops clinical and non-clinical staff. Supports recruitment efforts by interviewing, selecting, and training new staff. • Applies knowledge of HIPAA privacy and security regulations as well as URAC accreditation standards to ensure compliance in daily practice. • Coordinates staff orientation and training. Ensures staff provides services within any associated scope of practice and in compliance with organizational protocols, desk procedures, and policies. Provides staff training, including training aids. Documents and assesses effectiveness of staff training. • Supervises individual staff caseload and beneficiary needs to ensure timely delivery of care as well as productivity and timeliness requirements. • Evaluates clinical and non-clinical performance for quality, timeliness, and process consistency. Conducts regular and ad hoc case review audits, providing staff feedback regarding results and process improvement. Participates in the evaluation of the case management program. • Ensures compliance with TriWest policy and Health Care Services desk procedures.• Collaborates with medical providers, the Director, Case Management and the Medical Director for Case Management on program interpretation and guidance. • Participates in clinical and non-clinical performance improvement projects. Actively participates in meetings. • Monitors and provides input on the performance of non-clinical staff. • Supports department by covering case management and care coordination or carrying a case load as necessary. • Performs other duties as assigned. • Regular and reliable attendance is required CompetenciesCoaching / 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 challenging 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. Delegation Skills: Provide clear performance expectations for projects and ensure adequate access to resources for completion. 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, tactics, and strategies. 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 policies and procedures; Case Management, ECHO, Autism Care Demonstration, Referral Management, and Utilization Management principles; HIPAA Privacy and Security regulations; URAC accreditation standards, Managed Care concepts; community resources; alternative funding programs; medical management systems. Proficiency with International Classification of Diseases (ICD), Current Procedural Terminology (CPT), Healthcare Common Procedural Coding System (HCPCS). Working ConditionsWorking Conditions: • Availability to cover any work shift • Standard office environment or telecommuting options, minimal travel anticipated. • Extensive computer work with prolonged sittingCompany 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.BenefitsWe'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 Generous 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 Equal Employment OpportunityTriWest 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 cultivates and supports diversity at every organizational level, including hiring and retaining a diverse workforce, and we highly encourages candidates from all backgrounds to apply. Applicants are considered for positions 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.

Job Summary We offer remote work opportunities (AK, AR, AZ, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE,NV, NM, NC, ND, OK, OR, SC, SD, TX, UT, VA/DC, WI & WY only) Supervises daily operations of case management services and staff. Hires, trains, coaches, counsels, and develops staff. Monitors individual staff caseloads and beneficiary service levels to ensure delivery of quality and timely Case Management services. Ensures staff is fully informed of changes impacting their work by communicating updates, policy revisions, performance outcomes, and significant events. Advises non-clinical staff regarding Case Management support tasks. Supervisors are responsible for reviewing and understanding the scope of practice of their state of licensure as well as those of associated staff. **Veterans, Reservists, Guardsmen, and military family members are encouraged to apply**Education & ExperienceRequired: • Registered Nurse (RN) or Licensed Clinical Social Worker (LCSW), with a current unrestricted license • Case Manager Certification by a URAC-recognized entity • Three years full-time equivalent of direct clinical care to the consumer • Two Years Case Management or equivalent experience • One year supervisory experience or equivalent leadership role Preferred: • Bachelor's degree or higher in health-related field • Experience in Managed Care or TRICARE healthcare delivery system Key Responsibilities• Supervises the daily operations of case management services. Hires, trains, coaches, counsels, and develops clinical and non-clinical staff. Supports recruitment efforts by interviewing, selecting, and training new staff. • Applies knowledge of HIPAA privacy and security regulations as well as URAC accreditation standards to ensure compliance in daily practice. • Coordinates staff orientation and training. Ensures staff provides case management within scope of practice and in compliance with organizational protocols, desk procedures, and policies. Provides staff training, including training aids. Documents and assesses effectiveness of staff training. • Supervises individual staff caseload and beneficiary treatment plans to ensure delivery of care, productivity, and timeliness. Evaluates case manager practice for quality, timeliness, and process consistency. Conducts regular and ad hoc case review audits, providing staff feedback regarding results and process improvement. Participates in the evaluation of the case management program. • Ensures compliance with TriWest policy and Health Care Services desk procedures. • Collaborates with case managers, care coordinators, medical providers, the Director, Case Management and the Medical Director for Case Management on program interpretation and guidance.• Participates in clinical and non-clinical performance improvement projects. Actively participates in teleconferences and meetings. • Monitors and provides input on the performance of non-clinical staff. • Supports department by carrying a case load as necessary. • Performs other duties as assigned. • Regular and reliable attendance is required. CompetenciesCoaching / 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, 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. Delegation Skills: Provide clear performance expectations for projects and ensure adequate access to resources for completion. 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, tactics, and strategies. 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 policies and procedures, Case Management, Utilization Management, HIPAA Privacy and Security regulations, URAC accreditation standards, Managed Care concepts, Behavioral Health practices and principles, community resources, alternative funding programs, medical management systems. Proficiency with International Classification of Diseases, Current Procedural Terminology, Healthcare Common Procedural Coding System. Working ConditionsWorking Conditions: • Availability to cover any work shift • Works within a standard office environment, with minimal travel • Extensive computer work with prolonged sitting • Department of Defense security clearance requiredCompany 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.BenefitsWe'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 Generous 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 Equal Employment OpportunityTriWest 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 cultivates and supports diversity at every organizational level, including hiring and retaining a diverse workforce, and we highly encourages candidates from all backgrounds to apply. Applicants are considered for positions 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.

Job Summary We offer remote work opportunities (AK, AR, AZ, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE,NV, NM, NC, ND, OK, OR, SC, SD, TX, UT, VA/DC, WI & WY only) Supervises daily Utilization Management (UM) program operations. This position reports to a Manager of Utilization Management in either Prospective, Retrospective, or Appeals and Reconsideration for the TRICARE contract. The supervisor coordinates across teams to support meeting contractual metrics and timeliness, standardized clinical care requirements and accreditation standards. This position is responsible for supervision of UM performance and staff management. Development and preparation of operational reports. Functions as backup for staff during high volume periods. **Veterans, Reservists, Guardsmen, and military family members are encouraged to apply** Education & ExperienceRequired: • Registered Nurse, with current valid, unrestricted nursing license • 3+ years of job related experience in a healthcare environment • 3+ years supervisory or leadership experience in a healthcare environment • 2+ years utilization review or case management • U.S. Citizenship • Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation Preferred: • Medical/Surgical or Behavioral Health experience • Commercial Managed Care experience • Knowledge of government health care programs • Familiarity with utilization review criteria • CCM or HCQM certification • Knowledge of medical billing and coding • Prior experience with remote work environments Key Responsibilities• Supervises day to day UM operations to ensure operational effectiveness and efficiency. • Ensures staff is fully-informed of changes by communicating updates, policy revisions, performance outcomes, and significant events. • Prepares work schedules and monitors staff caseloads to ensure adequate staffing levels at all times and accurate data entry and application of the medical management system. • Monitors staff to ensure adherence to established criteria, including InterQyal, internally developed guidelines, decision support tools, contract requirements and TriWest policies and desk procedures. • Prepares reports for tracking and trending of UM activities. • Interprets reports and identifies UM opportunities to share with management. • Monitors the UM process and identifies and implements process improvements to ensure program quality assurance and compliance. • Reports Potential Quality Issues (PQI). • Responsible for interviewing and hiring new staff. • Provides coaching and oversight to staff to ensure staff success and development. • Assists with implementation, orientation and training of new staff.• Assists with the development of desk procedures, processes, workflow changes, and reports. • Systematically evaluates the quality and effectiveness of staff performance. • Advises and coaches when appropriate and completes annual performance appraisals. • Participates in meetings as required. • Collaborates across the clinical operations team for enhancing service levels. • Coordinates activities with contracted partners to meet Utilization Management (UM) Plan goals. • Completes special projects. • Regular and reliable attendance. • Performs other duties as assigned. CompetenciesCoaching / 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, 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. Delegation Skills: Provide clear performance expectations for projects and ensure adequate access to resources for completion Independent Thinking / Self-Initiative: Critical thinkers 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. Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment. Technical Skills: Thorough knowledge of policies and procedures, knowledge of managed care principles and methods; medical terminology; proficiency in the application of clinical criteria: InterQual, International Classification of Diseases, Diagnostic and Statistical Manual of Mental Disorders, current Procedural Terminology, and Healthcare Common Procedural Coding System, and American Dental codes; working knowledge with medical management systems; proficient with Microsoft Office; knowledge of UM Process; reporting techniques. Working ConditionsWorking Conditions: • Works non-regular hours, as required • Works remotely, with up to 10% travel • Ability to meet mandatory contract compliance timelines • Extensive computer work with prolonged sittingCompany 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.BenefitsWe'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 Generous 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 Equal Employment OpportunityTriWest 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 cultivates and supports diversity at every organizational level, including hiring and retaining a diverse workforce, and we highly encourages candidates from all backgrounds to apply. Applicants are considered for positions 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.

Veterans, Reservists, Guardsmen and military family members are encouraged to apply!!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, TX, UT, VA/DC, *WA, WI & WY only) Job Summary Supervises daily Utilization Management (UM) program operations. This position reports to a Manager of Utilization Management in either Prospective, Retrospective, or Appeals and Reconsideration for the TRICARE contract. The supervisor coordinates across teams to support meeting contractual metrics and timeliness, standardized clinical care requirements and accreditation standards. This position is responsible for supervision of UM performance and staff management. Development and preparation of operational reports. Functions as backup for staff during high volume periods.Education & Experience Required: • Registered Nurse, with current valid, unrestricted nursing license • 3+ years of job related experience in a healthcare environment • 3+ years supervisory or leadership experience in a healthcare environment • 2+ years utilization review or case management • U.S. Citizenship • Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation Preferred: • Medical/Surgical or Behavioral Health experience • Commercial Managed Care experience • Knowledge of government health care programs • Familiarity with utilization review criteria • CCM or HCQM certification • Knowledge of medical billing and coding • Prior experience with remote work environmentsKey Responsibilities • Supervises day to day UM operations to ensure operational effectiveness and efficiency. • Ensures staff is fully-informed of changes by communicating updates, policy revisions, performance outcomes, and significant events. • Prepares work schedules and monitors staff caseloads to ensure adequate staffing levels at all times and accurate data entry and application of the medical management system. • Monitors staff to ensure adherence to established criteria, including InterQyal, internally developed guidelines, decision support tools, contract requirements and TriWest policies and desk procedures. • Prepares reports for tracking and trending of UM activities. • Interprets reports and identifies UM opportunities to share with management. • Monitors the UM process and identifies and implements process improvements to ensure program quality assurance and compliance. • Reports Potential Quality Issues (PQI). • Responsible for interviewing and hiring new staff. • Provides coaching and oversight to staff to ensure staff success and development. • Assists with implementation, orientation and training of new staff.• Assists with the development of desk procedures, processes, workflow changes, and reports. • Systematically evaluates the quality and effectiveness of staff performance. • Advises and coaches when appropriate and completes annual performance appraisals. • Participates in meetings as required. • Collaborates across the clinical operations team for enhancing service levels. • Coordinates activities with contracted partners to meet Utilization Management (UM) Plan goals. • Completes special projects. • Regular and reliable attendance. • Performs other duties as assigned.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, 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. Delegation Skills: Provide clear performance expectations for projects and ensure adequate access to resources for completion Independent Thinking / Self-Initiative: Critical thinkers 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. Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment. Technical Skills: Thorough knowledge of policies and procedures, knowledge of managed care principles and methods; medical terminology; proficiency in the application of clinical criteria: InterQual, International Classification of Diseases, Diagnostic and Statistical Manual of Mental Disorders, current Procedural Terminology, and Healthcare Common Procedural Coding System, and American Dental codes; working knowledge with medical management systems; proficient with Microsoft Office; knowledge of UM Process; reporting techniques.Working Conditions Working Conditions: • Works non-regular hours, as required • Works remotely, with up to 10% travel • Ability to meet mandatory contract compliance timelines • Extensive computer work with prolonged sittingCompany 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.BenefitsWe'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 Generous 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 *Annual base salary for Colorado and Washington State residents: $95,000 - $106,000 depending on experience*Equal Employment OpportunityTriWest 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 cultivates and supports diversity at every organizational level, including hiring and retaining a diverse workforce, and we highly encourages candidates from all backgrounds to apply. Applicants are considered for positions 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.

Veterans, Reservists, Guardsmen and military family members are encouraged to apply!!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, TX, UT, VA/DC, *WA, WI & WY only) Job Summary Supervises daily Utilization Management (UM) program operations. This position reports to a Manager of Utilization Management in either Prospective, Retrospective, or Appeals and Reconsideration for the TRICARE contract. The supervisor coordinates across teams to support meeting contractual metrics and timeliness, standardized clinical care requirements and accreditation standards. This position is responsible for supervision of UM performance and staff management. Development and preparation of operational reports. Functions as backup for staff during high volume periods.Education & Experience Required: • Registered Nurse, with current valid, unrestricted nursing license • 3+ years of job related experience in a healthcare environment • 3+ years supervisory or leadership experience in a healthcare environment • 2+ years utilization review or case management • U.S. Citizenship • Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation Preferred: • Medical/Surgical or Behavioral Health experience • Commercial Managed Care experience • Knowledge of government health care programs • Familiarity with utilization review criteria • CCM or HCQM certification • Knowledge of medical billing and coding • Prior experience with remote work environmentsKey Responsibilities • Supervises day to day UM operations to ensure operational effectiveness and efficiency. • Ensures staff is fully-informed of changes by communicating updates, policy revisions, performance outcomes, and significant events. • Prepares work schedules and monitors staff caseloads to ensure adequate staffing levels at all times and accurate data entry and application of the medical management system. • Monitors staff to ensure adherence to established criteria, including InterQyal, internally developed guidelines, decision support tools, contract requirements and TriWest policies and desk procedures. • Prepares reports for tracking and trending of UM activities. • Interprets reports and identifies UM opportunities to share with management. • Monitors the UM process and identifies and implements process improvements to ensure program quality assurance and compliance. • Reports Potential Quality Issues (PQI). • Responsible for interviewing and hiring new staff. • Provides coaching and oversight to staff to ensure staff success and development. • Assists with implementation, orientation and training of new staff.• Assists with the development of desk procedures, processes, workflow changes, and reports. • Systematically evaluates the quality and effectiveness of staff performance. • Advises and coaches when appropriate and completes annual performance appraisals. • Participates in meetings as required. • Collaborates across the clinical operations team for enhancing service levels. • Coordinates activities with contracted partners to meet Utilization Management (UM) Plan goals. • Completes special projects. • Regular and reliable attendance. • Performs other duties as assigned.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, 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. Delegation Skills: Provide clear performance expectations for projects and ensure adequate access to resources for completion Independent Thinking / Self-Initiative: Critical thinkers 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. Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment. Technical Skills: Thorough knowledge of policies and procedures, knowledge of managed care principles and methods; medical terminology; proficiency in the application of clinical criteria: InterQual, International Classification of Diseases, Diagnostic and Statistical Manual of Mental Disorders, current Procedural Terminology, and Healthcare Common Procedural Coding System, and American Dental codes; working knowledge with medical management systems; proficient with Microsoft Office; knowledge of UM Process; reporting techniques.Working Conditions Working Conditions: • Works non-regular hours, as required • Works remotely, with up to 10% travel • Ability to meet mandatory contract compliance timelines • Extensive computer work with prolonged sittingCompany 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.BenefitsWe'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 Generous 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 *Annual base salary for Colorado and Washington State residents: $95,000 - $106,000 depending on experience*Equal Employment OpportunityTriWest 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 cultivates and supports diversity at every organizational level, including hiring and retaining a diverse workforce, and we highly encourages candidates from all backgrounds to apply. Applicants are considered for positions 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.

Responsible for delivering the highest quality health care within The Little Clinic's scope of services while achieving optimum patient satisfaction. These responsibilities include but are not limited to: building relationships with the patients, host store personnel and the health care community in order to enhance practice building and continuity of care. Demonstrate the company s core values of respect, honesty, integrity, diversity, inclusion and safety.At The Little Clinic, we are on a mission to simplify healthcare in America. We take pride in knowing we are helping individuals live healthier lives right in our communities. If you have a passion for helping others, we want to hear from you! Our clinics are staffed by board-certified nurse practitioners or physician assistants, licensed practical nurses, and patient care technicians who all work as a team to supply high-quality, affordable healthcare found in convenient retail settings. The primary focus of our healthcare team is to promote health and wellness through diagnosis and treatment of illnesses, preventative medicine, and individualized patient education. Here, people matter. That's why we strive to supply the ingredients you need to create your own recipe for success at work and in life. We help feed your future by supplying the value and care you need to grow. So, whether you're looking for balanced, competitive benefits and rewards or ongoing opportunities for growth and development- we have you covered. We are always looking for extraordinary talent to join our growing team! Minimum - Other Master of Science in Nursing as a Family Nurse Practitioner or Bachelors Degree as a Physician Assistant- 1 year of experience in healthcare- Ability to prioritize and handle multiple projects and responsibilities- Ability to maintain a high degree of confidentiality- Ability to work both independently and as part of a team- Excellent oral/written communication skills- Excellent telephone, interpersonal and organizational skills- Strong computer skills Desired - Any experience with applicable clinical procedures- Any experience with electronic health record charting systems- Any previous experience in retail health, emergency health, critical care- Demonstrated leadership, coaching and influencing skills- Provide the highest quality of medical care to our patients while maintaining all company metrics for productivity- Participate in and support Company initiatives and projects, including those that improve quality of care, achieve better health outcomes, focus on population health, collaborate with others to manage patients overall health and reduce cost of care for our patients- Participate in peer review, quality assurance, and staff meetings with other health practitioners as required- Ensure that a safety and quality-based healthcare environment is maintained- Ensure that the clinic remains open for all scheduled hours- Collaborate with the regional management in participating in a community event to promote TLC to generate increased utilization of the clinic- Respond as directed by regional management to correct any situations noted on the customer experience survey- Manage the clinic's inventory and order supplies to maintain cost effective clinical operations- Perform quality control on instrumentation and CLIA waived testing as scheduled- Utilize the company information systems as directed and in compliance with HIPAA regulations and company policies- Support mentor program by being a resource and a role model- Stay current with clinical best practices by attending ongoing education seminars related to retail, family practice and primary care- Provide coverage for clinics within the region as needed, and as assigned by the regional management- Control costs at the clinics to meet the budgeted profitability goals- Maintain a presence in the community through active membership in local nursing organizations and through participation in community outreach programs- Participate in other operational duties and responsibilities as assigned by the regional management- If a float: Travel to designated clinics within a specified geographic area- Must be able to perform the essential job functions of this position with or without reasonable accommodation

Communicate regularly with residents and their family about Plans of Care, PT, OT and other treatment protocols. • Attends and participates in morning meetings/stand up to facilitate communications with the team. • Answer residents' questions about their care, treatment plans, illness progression and all other issues so they feel safe and secure in our care. • Monitor and adjust resident's statuses based on changing needs and conditions. • Organize and prioritize daily work by assessing new, current and discharging residents needs in area(s) of responsibility. • Complete documentation as required. • Performs utilization review activities to provide resident appropriate, timely and cost-effective care. • Coordinate care with resident, care providers, facilities financial services, and third-party payers. • Oversee all admissions and discharge activities. • Coordinate referrals both to and from our facility. • Ability to relate positively, effectively, and appropriately with residents, families, staff and professional colleagues. • Accurate charting and ability to complete necessary paperwork in a timely manner. • Ability to work independently and exercise sound judgement in interactions with physicians, providers, payers and residents and their families. • Must be able to effectively communicate with, and promote cooperation and collaboration between individuals including residents/families/caretakers, physicians, nurse and other ancillary partners. • Must have excellent time management skills to develop organized work processes in a high-volume environment with rapidly changing priorities. • Intermediate computer skills. • Competence maintaining professional, respectful, honest interactions with residents/families and staff and partners. Supervisory Requirements This position has no supervisory responsibilities. Qualification Education and/or Experience Bachelor's Degree in Nursing or Social Work. Registered Nurse (RN) license preferred. Licensed (LVN or LPN) nurse acceptable. Two (2) year clinical nursing experience preferred. Knowledge of Medicare, Medi-cal and Medicaid programs and benefits. PCC Knowledge Language Skills Ability to read technical procedures. Ability to read and comprehend policy and procedure manuals. Ability to effectively present information and respond to questions from managers and employees. Mathematical Skills Ability to apply concepts such as fractions, percentages, ratios and proportions to practical situations. Reasoning Ability Ability to solve practical problems. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Certificates, Licenses, Registrations LVN/LPN Valid License or RN Valid Licensee in the state you are working. Certificate as a certified Case Manager (CCM) a plus. Must maintain all required continuing education/licensing. Must remain in good standing with the Department of Public Health; License and Certification Division at all times. Physical Demands The essential functions of this position require the following physical abilities: Standing and /or walking very frequently. Sitting occasionally. Reaching with hands and arms frequently, pushing/pulling very frequently. Talking and /or hearing very frequently. Tasting and /or smelling very frequently. Lifting up to 50 pounds frequently. Climbing, balancing, stooping, kneeling, crouching or crawling occasionally. Close, distance, color, peripheral, and depth perception in vision: ability to adjust focus. Work Environment The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually low to moderate. Additional Information Note: Nothing in this job specification restricts management's right to assign or reassign duties and responsibilities to this job at any time. Critical features of this job are described under various headings above. They may be subject to change at any time due to reasonable accommodation or other reasons. The above statements are strictly intended to describe the general nature and level of the work being performed. They are not intended to be construed as a complete list of all responsibilities, duties, and skills required of employees in this position.