TriWest Healthcare Alliance

  • Claims Reviewer

    Recruiting Location Phoenix, AZ
    ID 2019-2768
  • Overview

     Work Location:  Phoenix, AZ

     

    Claims Reviewer at TriWest Healthcare Alliance

     

    Taking Care of Our Nation’s Veterans.

    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.

     

    Are you our next Claims Reviewer?

    Responsibilities

    TriWest Claims Reviewer:

    Conducts retrospective review of medical/surgical claims and behavioral health claims s for inpatient and outpatient services.  Applies clinical, coding and processing knowledge to conduct review and process claims.   Compiles information necessary to prepare cases program payment.  Ensures adherence to program benefits as authorized.  Provides clinical and coding-related information to medical director, providers, peer reviewers, Claims Administration, Program Integrity, Quality Management and the claims subcontractor as needed.  Advises clinical and non-clinical staff on claims and coding questions.

    .

    • Conducts medical claims review using current claims processing guidelines and established clinical criteria e.g. CDST and policy keys, to evaluate medical necessity, appropriateness of care and program benefits, exclusions and limitations.
    • Validates medical determinations through research of resources including regulatory manuals, computer files and documentation.
    • Prepares cases program payment or medical director review as indicated.
    • Validates all appropriate data is supplied with program invoice.
    • Reviews claim data for process improvements related to all aspects of claims payment
    • Ensures contract compliance for timelines regarding resolution of medical claims.
    • Communicates effectively with management and peers.
    • Consistently meets medical claims processing quotas.
    • Identifies and reports any potential quality or fraud issues to management, Quality Management or Program Integrity as needed.
    • Provides support regarding clinical and coding questions.
    • Performs other duties as assigned.
    • Regular and reliable attendance is required.

    Qualifications

    Are you qualified?

    • Are you a Veteran, family member of a Veteran, a friend of a Veteran, or passionate about helping Veterans?
    • Do you have your High School diploma or G.E.D?
    • Do you have 2+ years claims review experience?
    • Do you have Knowledge of all types of Medical claims review?
    • Do you have Knowledge of Behavioral health claims review?

    Preferred

    Do you have Claim coding experience?

    More about Working at TriWest Healthcare Alliance

    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 

    Equal Opportunity Employer

    TriWest Healthcare Alliance is an equal employment opportunity employer. All qualified applicants are considered for employment, without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other characteristic made unlawful by applicable federal, state, or local laws.

     

    Are you ready to make a difference in the lives of our nation’s heroes?

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