FULL_TIME

FEED

OTHER

Functions on TriWest standing and ad hoc committees as a representative of the Legal department including, but not limited to, committees responsible for TriWest's peer review, quality, and credentialing programs. • Experience advising managed care administrators, health plans, or healthcare providers, • Familiarity with HIPAA, False Claims Act, Stark, Anti-Kickback and other healthcare-related laws & regulations.

TriWest Healthcare Alliance

Assoc Gen Counsel - Healthcare

equestftpin

Ensures accuracy and completion of authorization data from customer information, medical records, referral/authorization forms, Military Treatment Facility electronic transmission and other documents into medical management system. Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.

Referral Specialist

Technical Skills: Thorough knowledge of policies and procedures, knowledge of managed care principles and methods; medical terminology; proficiency in the application of clinical criteria: InterQual, International Classification of Diseases, Diagnostic and Statistical Manual of Mental Disorders, current Procedural Terminology, and Healthcare Common Procedural Coding System, and American Dental codes; working knowledge with medical management systems; proficient with Microsoft Office; knowledge of UM Process; reporting techniques. • Prepares work schedules and monitors staff caseloads to ensure adequate staffing levels at all times and accurate data entry and application of the medical management system.

Supervisor, Utilization Management

The Transition of Care Coordinator provides clinical oversight and coordination for beneficiaries moving between levels of care, supports discharge planning, conducts post-discharge follow up, completes assessments and reassessments as needed, identifies barriers to care, and reviews and processes authorization and referral requests according to policy. Technical Skills: Thorough knowledge of internal policies and procedures, utilization management principles, managed care concepts, medical terminology, and medical management system, clinical decision support tools, International Classification of Diseases, and Current Procedural Terminology.

Transition of Care Coordinator RN/LCSW

Complies with the Veterans Affairs Community Care Network (CCN) and TRICARE T-5 contracts; DHA and TRICARE program guidelines and pertinent Federal regulatory requirements; assists supervisors with FWA trending and reporting requirements; coordinates and assists with investigations and prosecutions by federal agencies interfaces directly with Veterans, Military members and family (as warranted), providers, subcontractors, and other TriWest departments on FWA issues; assist supervisor with the education and training of TriWest, subcontractor, and provider personnel on current FWA matters; prepares appropriate responses to provider compliance issues and complaints referred to Program Integrity by other TriWest departments or external referrals. The PI Investigator t is responsible for the identification, analysis, case development, and reporting of suspected fraud, waste and abuse (FWA) cases as defined by the Department of Veterans Affairs (VA), the Healthcare Finance Administration (HCFA) and the Department of Defense, Defense Health Agency for the TRICARE program; requests and reviews issue-related medical claims and records for FWA and/or administrative and clerical error(s).

Program Integrity Investigator

This leader will collaborate with data management to utilize predictive and prescriptive analytics to stratify our beneficiary population for inclusion in multiple Medical Management programs; direct staff and interventions that will improve beneficiary health outcomes including HEDIS scores; develop and implement clinical programs to optimize Condition/Disease Management strategies and goals; and collaborate with leadership to enhance the overall healthcare education and knowledge of our beneficiaries using multiple platforms and experiences. Technical Skills: Advanced knowledge of managed care principles; working knowledge of medical necessity review criteria, LOS, ICD, CPT, HCPCs and American Dental Coding required; quality management training/experience; extensive experience with relational databases and statistical analysis.

Director, Population Health

UNKNOWN

This role is ideal for a highly technical AI architect who enjoys solving complex business problems, building innovative GenAI solutions, and driving enterprise AI adoption from concept through implementation. Technical Requirements Experience with several of the following technologies: Large Language Models (OpenAI, Claude, Gemini, Llama, etc.).

Expert In Recruitment Solutions

GenAI Solutions Architect

jobdiva

This leader will report to the Manager of Case Management Special Programs under the overall Case Management Special Programs umbrella, specifically supporting TRICARE beneficiaries seeking benefits under Extended Care Health Option (ECHO) and Autism Care Demonstration (ACD). Problem Solving / Analysis: Ability to solve problems through systematic analysis of processes with sound judgment; has a realistic understanding of relevant issues, tactics, and strategies.

Sup, Case Mgmt Sp Prgms Ops

Accurately and professionally answer health care inquiries and provide resolutions to TRICARE beneficiaries & providers over the phone, chat, email or other written correspondence. • Effectively and professionally answer customer inquiries by taking ownership of issues, utilizing sound judgement and the tools at your disposal to resolve customer issues on the initial contact.

TRICARE Customer Service Rep

In support of TRICARE beneficiaries enrolled in the Autism Care Demonstration (ACD), the Autism Services Navigator (ASN) collaborates and oversees the assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services for TRICARE beneficiaries diagnosed with autism spectrum disorder (ASD). • Current unrestricted licensure in an appropriate state or territory of the United States, as a Licensed Independent Clinical Social Worker (LICSW), Licensed Clinical Social Worker (LCSW), Registered Nurse, or other licensed mental health professionals who possess a Certification in Case Management (CCM).

Autism Services Navigator

Functions as an advocate for the beneficiary by ensuring access to necessary care and maintaining Beneficiary's safety, locating specialized services outside the network by identifying providers, exploring nature of services offered, and facilitating process. Independent Thinking / Self-Initiative: Resourceful critical thinker who is able to prioritize tasks essential to achieving desires outcomes, demonstration a proactive commitment to task completion and the ability to identify and secure necessary resources.

Case Manager

4 years of experience with scheduling software, workforce management software or equivalent, and telephony systems, or 2 years of TriWest experience as a Workforce or Performance Reporting Analyst or Contact Center Supervisor with scheduling software, workforce management software or equivalent, and telephony systems. Independent Thinking / Self-Initiative: Critical thinkers with ability to focus on things which matter most to achieving outcomes; commitment to task to produce outcomes without direction and to find necessary resources.

Workforce Analyst Sr - TRICARE

Develop compelling proposal content that clearly articulates TriWest's unique capabilities, market expertise, provider relationships, analytical capabilities, and demonstrated ability to build and maintain networks that meet complex customer requirements. The Director of Network Strategy is responsible for developing and executing TriWest's enterprise strategy for network adequacy and network optimization across its VA Community Care Network (CCN) and TRICARE programs.

Dir, Provider Network Strategy

YEAR

This position is heavily focused on maintaining and strengthening relationships with end-user customers across multiple market segments such as healthcare, education, hospitality, and other commercial segments . The ideal candidate will: Our ideal candidate has prior experience of specifying commercial building products in projects with architects, interior designers, and facility end users.

Macpower Digital Assets Edge Private Limited

Territory Sales Manager

TriWest will prioritize candidates with experience with healthcare regulatory matters, including Medicare and Medicaid and conditions of participation in federal healthcare programs, anti-kickback laws, self-referral laws, HIPAA, and transactional matters for health care providers. Supports the Office of General Counsel in advising and producing attorney work products that support TriWest's healthcare-related departments including, but not limited to, Provider Services, Medical Management, Program Integrity, and Claims.

Healthcare Counsel

Technical Skills: In-depth knowledge of all application functionality, security, development, and system administration; knowledge of relevant technology, tools and middleware; proficient change agent; knowledge of the agile methodology and software maintenance and support. • Develops and maintains ongoing relationships with hardware, software, consultant, and employee resource vendors to insure that TriWest systems are adequately supported and external opportunities are understood and considered in the planning process.

Manager, Data Engineering (Master Data Management) MDM

Experience in case management, care coordination or discharge planning in an acute, ambulatory or specialty disease management program settings in a healthcare system or managed care organization (MCO). The DM nurse will partner with the interdisciplinary care team to identify appropriate care to prevent complications related to chronic conditions and minimize the risk of potential exacerbation through the use of evidence-based condition-specific education and coaching.

RN Disease Manager (Behavioral Health Experience Required)

The Training Specialist is responsible for delivering high-quality training programs to TriWest employees and external stakeholders, including beneficiaries, Providers, and DHA employees. • Assist with training department-specific needs, including compliance with the department policies and procedures, maintaining required training documentation, participating in process improvement meetings, and other duties as appropriate and requested.

Training Specialist

Your level of success will be determined by several factors, including the amount of work you put in, your ability to successfully follow and implement our training and sales system and engage with our lead system, and the insurance needs of the customers in the geographic areas in which you choose to work. By submitting this form, you agree to recurring contact from Symmetry Financial Group LLC and its affiliated companies under common control and their insurance agents via text & live, automated, A.I., or prerecorded calls, including for marketing or recruiting purposes.

The Gray Agency

Remote Insurance Agent (Licensed or Unlicensed)

appcast_organic

10+ years hands-on Vistex implementation and support experience. Excellent communication and stakeholder management skills.

Work From Home Jobs in Riverview, FL

Assoc Gen Counsel - Healthcare TriWest Healthcare Alliance

Referral Specialist TriWest Healthcare Alliance

Supervisor, Utilization Management TriWest Healthcare Alliance

Transition of Care Coordinator RN/LCSW TriWest Healthcare Alliance

Program Integrity Investigator TriWest Healthcare Alliance

Director, Population Health TriWest Healthcare Alliance

GenAI Solutions Architect Expert In Recruitment Solutions

Sup, Case Mgmt Sp Prgms Ops TriWest Healthcare Alliance

TRICARE Customer Service Rep TriWest Healthcare Alliance

Autism Services Navigator TriWest Healthcare Alliance

Case Manager TriWest Healthcare Alliance

Workforce Analyst Sr - TRICARE TriWest Healthcare Alliance

Dir, Provider Network Strategy TriWest Healthcare Alliance

Territory Sales Manager Macpower Digital Assets Edge Private Limited

Healthcare Counsel TriWest Healthcare Alliance

Manager, Data Engineering (Master Data Management) MDM TriWest Healthcare Alliance

RN Disease Manager (Behavioral Health Experience Required) TriWest Healthcare Alliance

Training Specialist TriWest Healthcare Alliance

Remote Insurance Agent (Licensed or Unlicensed) The Gray Agency

SAP VISTEX ARCHITECT Echo IT Solutions, Inc

Similar Job Searches

Stand out to leading employers.