Remote Clinical Quality Reviewer

Chenega Corporation

6d•$80,000 - $90,000•Remote

About The Position

Come join a company that strives for Extraordinary People and Exceptional Performance! Chenega Services & Federal Solutions, LLC, a Chenega Professional Services’ company, is looking for a fully remote Clinical Quality Reviewer to ensure compliance with the contract, and program requirements for Clinical Quality Management (CQM) within TRICARE West Region. To ensure quality care is delivered for TRICARE beneficiaries by identifying, investigating, and evaluating medical records retrospectively for potential quality, safety, and utilization issues by using organizational, national, TRICARE, and URAC standards for consistency. Supports activities of peer review and quality and safety committees. Our company offers employees the opportunity to join a team where there is a robust employee benefits program, management engagement, quality leadership, an atmosphere of teamwork, recognition for performance, and promotion opportunities. We actively strive to channel our highly engaged employee’s knowledge, critical thinking, innovative solutions for our clients.

Requirements

H.S. diploma or GED required bachelor’s in nursing or bachelor’s degree in a health care field or Certified Professional in Healthcare Quality (CPHQ) preferred.
Registered Nurse or Licensed Clinical Social Worker, with current unrestricted license in appropriate state.
3 years clinical experience (medical, surgical, and or behavioral health).
Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation.
Knowledge, Skills and Abilities:
1 year experience in Clinical Quality Management.
1 year experience with data analysis and reporting.
Experience with InterQual criteria or similar criteria sets.
General knowledge of Medicare, TRICARE, or other government healthcare programs.

Responsibilities

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 AHRQ concerns and documents a rationale for cases when TriWest's position does not concur with the AHRQ position.
Requests Practice Pattern Analyses (trend) to assist with identifying physician practice patterns for confirmed severity cases.
Identifies and refers cases for focused reviews to Clinical Quality Management Leadership.
Performs focused study data collection, reporting, analysis, and makes recommendations for improvement.
Refers cases for review as appropriate to Program Integrity, Case Management, Care Coordination, Population Health Improvement, Disease Management, Congressional Relations & Customer Grievances and other TriWest departments.
Participates on quality committees.
Reviews Potential Quality Issues with Medical Directors when appropriate.
Other duties as assigned.