Claims Reviewer- Quality/Audits (Finance)

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).

Veterans, Reservists, Guardsmen and military family members are encouraged to apply!

Job Summary

Conducts retrospective review of medical/surgical claims and behavioral health claims for inpatient and outpatient services, as it relates to claims inquiry, resolution, audit, and related functions. Applies clinical, coding, and processing knowledge to conduct review of claims. Validates and compiles information necessary to prepare cases for program payment. Ensures adherence to Government contract requirements. Provides clinical and coding-related information to medical director, providers, peer reviewers, Claims Administration, Program Integrity, Quality Management, and/or the Claims Subcontractor as needed. Advises clinical and non-clinical staff on claims and coding questions.

Education & Experience

Required:

• High School Diploma or GED
• 2 years of claims review experience
• Knowledgeable in medical, institutional, and behavioral health claims processes
• Demonstrated ability to communicate effectively, both verbally and in writing
• Experience using MS Word, Excel, and Office

Preferred:

• Government claims experience
• Claims coding certification or equivalent experience
• Intermediate proficiency with MS Office suite

Key Responsibilities

• Validates claim outcomes for accuracy and routes for adjustment, as necessary.
• Conducts medical claims review using current claims processing guidelines and established clinical and program criteria.
• Validates claims submission details against systems data.
• Adheres to all desktop procedures for assigned function.
• Identifies and appropriately communicates processing discrepancies or trends.
• Reviews claim data for process improvements.
• Communicates effectively and professionally with internal and external partners.
• Consistently meets or exceeds individual performance expectations.
• Identifies and reports potential quality or fraud issues to per established procedures.
• Performs other duties as assigned.
• Regular and reliable attendance is required.

Competencies

Coaching / Training / Mentoring: Actively foster actions required for desired business outcomes through ongoing constructive feedback.

Commitment to Task: Ability to conform to established policies and procedures; exhibit high motivation.

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.

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: Thorough knowledge of policies and procedures, Managed Care concepts and medical terminology. Proficient with claim and coding tools and resources, Clinical Decision Support Tool, Current Procedural Terminology, Health Care Financing Administration Common Procedure Coding System, and American Dental coding. Ability to meet or exceed production standards in compliance with contract.

Working Conditions

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 workspace and workstation 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

We'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, Hawaii, Washington D.C. and Washington State residents: $54,913.37- $57,964.10 depending on experience*

Equal Employment Opportunity

TriWest 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.