Remote Clinical Quality Reviewer

Chenega Corporation

415d • $80,000 - $90,000 • Remote

About The Position

The Clinical Quality Reviewer at Chenega Corporation is responsible for ensuring compliance with contract and program requirements for Clinical Quality Management (CQM) within the TRICARE West Region. This role involves reviewing medical records to identify potential quality, safety, and utilization issues, ensuring that quality care is delivered to TRICARE beneficiaries. The position supports peer review and quality committees, contributing to the overall quality improvement initiatives of the organization.

Requirements

• H.S. diploma or GED required; bachelor's in nursing or 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.
• 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, including researching, investigating, analyzing, and preparing case summaries with 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 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.

Benefits

• Robust employee benefits program
• Management engagement
• Quality leadership
• Atmosphere of teamwork
• Recognition for performance
• Promotion opportunities

What This Job Offers

• Job Type: Full-time
• Industry: Administrative and Support Services
• Education Level: High school or GED