Clinical Quality Review Team Lead

Job Summary

The position is responsible for supporting Clinical Quality Management (CQM) staff production and quality processes; assisting in the development of policies and procedures related to CQM; meeting CQM contractual requirements focused on TRICARE Quality Monitoring Contract (TQMC) requirements and ensuring compliance with URAC standards. The team lead supports clinical and non-clinical staff supporting CQM programs by providing training and onboarding of new staff; determining work assignments; performing audits for clinical records and/or work accuracy; and ensuring effective, consistent and accurate workflow. The position also assists the Supervisor and Manager in developing study topics, quality improvement processes and reporting in support of the CQM program.

Education & Experience

Key Responsibilities

• Provides support to Clinical Quality clinical and non-clinical daily operations and ensures timeliness and accuracy of work to meet all contract requirements, particularly those related to TQMC.
• Assists the supervisor in assigning cases appropriately according to clinicians' scope of practice.
• Monitors and ensures appropriate and accurate focused study data collection, analysis, and reporting.
• Provides input regarding training modules on quality management basics for teaching staff.
• Trains and mentors Clinical Quality staff.
• Identifies, develops, and monitors focused reviews and other quality studies. Keeps Supervisor informed of issues related to quality studies and PQIs.
• Provides accurate communications on case reviews.
• Performs staff audits and develops summary reports.
• Ensures adherence to accreditation standards, TRICARE policy, contractual requirements and nationally recognized practice standards.
• Participates in 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 analyze data supporting focused reviews and quality studies.
• Refers cases to supervisor for review as appropriate to and from Program Integrity, Case Management, Provider Services, Congressional and Customer Relations, and other TriWest departments.
• Supports TriWest committees as a representative of Clinical Quality Management.
• 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.

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.

Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment.

Technical Skills: Comprehensive knowledge of research methodology; proficient applying appropriate data analysis processes; knowledge of managed care principles and methods; knowledge in the application of clinical criteria; proficient with Microsoft Word, Excel, and PowerPoint.

Working Conditions

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.

Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.

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
• 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

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 supports diversity at every organizational level, and we highly encourage candidates from all backgrounds to apply. Applicants are considered for positions based on merit and 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.