TriWest Healthcare Alliance

Investigate and report suspected fraud, waste, and abuse in healthcare claims, ensuring compliance with federal regulations and coordinating with various stakeholders. | Requires 2 years of fraud investigation or claim auditing experience, US citizenship, DoD background check, knowledge of healthcare billing and claims analysis, and high school diploma or GED. | Profile We offer remote work opportunities (AK, AR, AZ, CO, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, WA, WI & WY only). Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position. Veteran, Military Spouse or Military Affiliated are encouraged to apply! Job Summary This position is under the general guidance of the Director, Program Integrity and reports directly to the Supervisor, Program Integrity. 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). 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. Education & Experience Required: • 2 years of experience in fraud, waste and abuse investigations, or equivalent claim auditing experience • U.S. Citizenship • Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation • Experience with data analysis techniques, to include Excel and/or SQL expressions • High School Diploma or GED required • Experience with quality review standards and healthcare claims analysis techniques • Knowledge of medical billing regulations and practices, as well as standard healthcare benefits and exclusions Preferred • Knowledge of current trends in healthcare fraud, waste and abuse • Knowledge of CMS benefits and policies • Knowledge of Facets • Certified Coder (CPC, CPC-P, CCA, CCS-P), AHFI, or other related certification • Experience with IBM’s Fraud and Abuse Management System (FAMS) and Case Manager Solutions • Experience with PeopleSoft and MS Office Suite Key Responsibilities • Independently researches FWA issues and effectively employs investigative resources/techniques in achieving projected PI performance goals and outcomes, requiring minimal direction. • Maintains the confidentially and non-discoverability of all fraud and abuse, quality assurance, quality management, and risk management issues. • Reconciles special, unresolved issues associated with beneficiary and provider inquires. • Facilitates and supports Program Integrity goals, objectives, and contract compliance. • Readily accesses and interprets VA, DHA, TRICARE and TriWest guidelines, policies and procedures. • Effectively utilizes appropriate data systems as provided and required by TriWest to identify, research, document and track fraud and abuse issues and activities. • Participates in and/or completes VA, DHA/TRICARE directed leads, audits, investigations, data collection, and medical. • Record reviews for fraud and abuse case development. • Proactively identifies and researches potential fraud and abuse issues. • Performs as a witness in court as requested. • Researches and investigates health care fraud issues, claims data, medical records as they relate to potential fraud and abuse cases (i.e.; problem provider issues). • Prepares and submits medical records for PI clinical review as appropriate. • Ensures accuracy, completeness, and timely submission of all required leads, reports, audits, and case development activities and documents. • Coordinates/liaises with TriWest departments, PGBA POC’s, and government agencies in researching, determining, and reporting FWA issues. • Participates in and contributes to PI education and training for beneficiaries, providers, subcontractor, and TriWest interdepartmental personnel regarding fraud and abuse. • Assists supervisor in the preparation and compilation of monthly, quarterly, semiannual, and special reports as required. • Participates in system enhancements for reporting fraud and abuse activities. • Facilitates the development of Program Integrity materials for staff, provider and beneficiary education and training as well as assist other departments with educational requests. • Facilitates the development of Program Integrity materials for provider seminars, provider newsletter, and quarterly bulletins. • Assists in the development of quality studies as directed by TriWest Medical Directors. • Assists supervisor with the annual review of PI policies and desk procedures. • : • Demonstrates effective use of documentation systems for communication, tracking, trending, and reporting purposes. • Research and prepare appropriate and timely responses to beneficiaries, provider and congressional compliant issues referred to Program Integrity by other company departments. • Interfaces with all levels of TriWest employees and maintains effective working relationships while adhering to all customer service goals and guidelines. • Demonstrates flexibility and adaptability towards achieving PI departmental performance/production goals and objectives. • Routinely processes recoupment requests, live claims, and performs other duties as assigned. Attends and participates in continuous training opportunities in current schemes and trends related to FWA. • Participates in and contributes to FWA information-sharing resources, task forces, and joint investigative efforts. • Regular and reliable attendance is required. Competencies Commitment to Task: Ability to conform to established policies and procedures; exhibit high motivation. Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate. 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. 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. Information Management: Ability to manage large amounts of complex information easily, communicate clearly, and draw sound conclusions. 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. Technical Skills: Knowledge with CPT4, ICD-10-CM, HCPCS, DRG and Revenue Code coding conventions. Knowledge of standard benefit coverage policies and exclusions, including National and Local Coverage Determinations. Knowledge of standard healthcare billing regulations and practices. Working Conditions Working Conditions • Availability to work any shift • Works in a standard office environment, with minimal travel • Extensive computer work with prolonged sitting Company Overview 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. DoD Statement Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position. Benefits 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 job postings typically include a salary range, which can vary based on the specific role and location, but generally this position ranges from around $64,000 to $68,000 per year. Equal Employment Opportunity 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.

Oversee and ensure high-quality training delivery across an organization, manage training teams, and align training programs with organizational goals. | Requires 5+ years in training delivery or facilitation, 2+ years in a supervisory role, and relevant educational background, with a preference for experience in instructional design and adult learning. | Profile We offer remote work opportunities (AK, AR, AZ, CO, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, WA, WI & WY only). Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position. Veterans, Reservists, Guardsmen and military family members are encouraged to apply! Job Summary The Manager of Training Delivery is responsible for overseeing the facilitation and execution of training programs across TriWest, ensuring consistent, high-quality delivery to employees and external stakeholders. This role manages a team of training specialists and ensures that training aligns with organizational priorities, compliance requirements, and performance goals. The Training Delivery Manager provides ongoing coaching, performance feedback, and professional development opportunities for trainers, fostering a culture of excellence and continuous improvement. This role is responsible for the oversight, coordination and delivery of all live virtual training, and traditional classroom training for all TriWest's internal and selected external audiences. This includes creating and managing company-wide live training development standards, expectations, and measurements that build employee competencies in an environment of continuous learning. Education & Experience Required: • Bachelor's Degree in education, instructional design, instructional technology, organizational development, HR, or related discipline or related field; OR equivalent experience, to include any combination of education and experience • U.S. Citizen • Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation • 5 years of experience in training delivery, facilitation, or corporate learning leadership • 2 + years in a formal people supervisor or manager role Preferred • Master’s Degree in education, instructional design, instructional technology, organizational development, HR, or related discipline or related field • Experience in all phases of the design, development, implementation, facilitation, measurement and evaluation and delivery of technical and non-technical programs using appropriate adult learning theories Key Responsibilities • Leads and supervises a team of Training Specialists to ensure effective facilitation of TriWest-approved content. • Oversees the delivery of onboarding, role-specific, compliance, and external stakeholder training programs. • Assists training logistics team with the coordination of training schedules, resources, and logistics to support seamless execution. • Ensures consistency and quality in training delivery across multiple audiences and formats. • Supporting minor content updates and collaborating with instructional design teams for larger revisions. • Monitors training effectiveness through feedback, assessments, and performance metrics. • Partners with leadership to align training delivery with organizational goals and compliance standards. • Conducts regular observation and evaluation of training sessions to assess delivery effectiveness and provide constructive coaching and feedback. • Develops trainer performance metrics and track progress toward individual and team goals. • Drives continuous improvement of facilitation practices, leveraging participant feedback, performance data, and industry best practices. • Serves as an escalation point for delivery-related issues and ensures timely resolution. • Performs other duties as assigned. 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. Empathy / Customer Service: Customer-focused behavior; helping approach, including listening skills, patience, respect, and empathy for another's position. 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. Stays informed of emerging trends and tools to continuously improve the effectiveness of learning programs. Leadership: Successfully manage different styles of employees; provide clear direction and effective coaching. Multi-Tasking / Time Management: Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environment. Problem Solving / Analysis: Ability to solve problems through systematic analysis of processes with sound judgment; has a realistic understanding of relevant issues. Technical Skills: Knowledge of the operation of a learning management system (LMS) with knowledge of AICC and SCORM interoperability standards; knowledge of live online platforms, and course development for live online delivery. Understands and applies current principles of adult learning, instructional design, and training delivery. Working Conditions Working Conditions • Regular and reliable attendance is required • Works in a standard office environment, with 10% - 20% travel • Extensive computer work with prolonged sitting • Level II IT security clearance required Company Overview 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. Benefits 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 job postings typically include a salary range, which can vary based on the specific role and location, but generally this position ranges from around $95,000 - $106,000 per year. Equal Employment Opportunity 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.

Provide workforce management support by tracking staffing levels, analyzing performance metrics, compiling reports, and collaborating with teams to improve call center productivity. | US citizenship with DoD clearance, 1+ year call center experience, knowledge of workforce management concepts, intermediate Excel skills, and ability to write procedural communications. | Profile We offer remote work opportunities in the following locations ONLY: AK, AR, AZ, CO, DC, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA, WA, WI, WY. US Citizenship Required - Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position. Veteran, Military Spouse or Military Affiliated are encouraged to apply! Job Summary This position is responsible for providing direct Workforce Management support. It focuses on staffing levels and applies workforce management techniques and concepts to improve productivity outcomes. Techniques include real time adherence (RTA), routine performance snapshots, communications, attendance tracking and processing customer requests. Education & Experience Required: • Must be a U.S. Citizen • Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation • High School Diploma or G.E.D. • 1+ years call center experience • Working knowledge of call center operations and workforce management concepts/methodology • Intermediate skill in Microsoft Excel • Knowledge of metrics reporting • Experience writing instructional or procedural communications or documents Preferred • Bachelor’s degree in informatics, business administration or related field • 2+ years in customer service in a call center environment • Experience with data analysis, performance metrics, problem identification, and data reporting • Experience with scheduling software, workforce management software, or equivalent • Experience with telephony systems Key Responsibilities • Utilizes performance metrics to track actual performance against standards. • Compiles data, organizes into meaningful format, and analyzes performance levels. • Identifies operational issues and trends, performs data reconciliation, and develops data reports. • Maintains routine performance snapshots and inventory status. • Uses business contingency plans to address performance. • Develops new ways to measure outcomes, performs data compilation and analysis to document business process outcomes. • Uses on-going data collection and analysis to ensure attainable and reasonable standards are managed successfully. • Compiles, assesses, and communicates departmental, unit, and individual performance measurements. • Develops monthly audit reports to track changes. • Assesses performance standards to ensure compliance with TriWest standards and government requirements. • Participates in the assessment of new technology to enhance operational outcomes. • Assists with the development and maintenance of new databases to track performance measures, costs, and operational data. • Takes active steps to ensure data and process integrity. • Collaborates with team on operational trending, data analysis, and reporting functions. • Partners with other TriWest departments to identify, address, and resolve process issues to ensure high quality service levels throughout TriWest. Seeks advice and escalates issues or problems as warranted. • Works closely with leadership teams to achieve goals and performance standards. • Performs all other duties assigned. • Regular and reliable attendance is required. Competencies 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. 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. Information Management: Ability to manage large amounts of complex information easily, communicate clearly, and draw sound conclusions. Multi-Tasking / Time Management: Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environment. 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: Knowledge of workforce management concepts and methodology, statistical data analysis and statistical quality control; performance metrics, continuous process improvement; writing skills, including structure and grammar; research skills; expertise in report development, data presentation, and writing formal recommendations; collaboration and project management skills; ability to maintain confidentiality with proprietary issues. Proficient with records maintenance and call center software; proficient with Microsoft Word, Excel, PowerPoint, and Project. Working Conditions • Ability to cover any work shift • Ability to work overtime, if needed • Onsite: Works within a standard office environment • Remote: Private and secure workspace and workstation with high-speed internet is required. • Extensive computer work with prolonged sitting, wearing of headset, typing, speaking on a phone Company Overview 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. Benefits 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 job postings typically include a salary range, which can vary based on the specific role and location, but generally this position ranges from around $53,000 to $59,000 per year. Equal Employment Opportunity 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.

Provide training and daily direction to claims customer service representatives, resolve complex claims issues, collaborate with internal and external stakeholders, and ensure compliance with HIPAA and department productivity goals. | High school diploma or GED, 1 year call center experience, 2 years claims resolution or billing experience, proficiency with Microsoft Office, strong communication skills, and knowledge of medical terminology. | Profile We offer remote work opportunities (AK, AR, AZ, CA, *CO, FL, *HI, IA, ID, *IL, KS, LA, MD, *MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, *WA, WI & WY only). Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position. Veterans, Reservists, Guardsmen and military family members are encouraged to apply! Job Summary As part of the claims escalation team, provides training, resolution and daily direction to the Claim Customer Service Representatives. Supports team by researching claims data, claim system, and authorizations to resolve provider claims questions. Interacts with outside entities and internal departments to resolve claims inquiries. Utilizes multiple software applications, applies business rules, and knowledge of provider or authorizations to resolve provider claims questions. Works under timelines while meeting accuracy and production goals. Education & Experience Required: • High School diploma or G.E.D. • One year experience working in a call center • Proficient with Microsoft Outlook, Word and Excel • Strong Knowledge of medical terminology • 2 years claims resolution, billing experience or demonstrated success as a TriWest Claims Customer Service Representative • Strong written and verbal communication skills Preferred • Associates degree in healthcare or related field Key Responsibilities • Reviews, analyzes and directs resolution of complex claims issues. • Interfaces with Claims and CCOPs leaders, CSRs, other internal departments, VA and vendors. • Serves as a Subject Matter Expert to Claims Customer Service Representatives and other internal departments. • Investigates recurring problems, identifying process improvements and reporting findings to leadership. • Tracks daily questions and resolution trends. • Documents all communications involving staff, Veteran, and provider contacts. • Reviews large amounts of complex information from multiple sources, including validating appropriate data on claim. • Collaborates with Claims sub-contractor to build or update authorization and provider records. • Participates in training documentation creation and updates. • Manages multiple task lists in accordance within directed timelines. • Maintains updated knowledge of software applications, Claims trends, and Claim CSRs’ procedures and processes. • Complies with HIPAA regulations to protect privacy of health information. • Consistently meets department productivity and performance metrics. • Manages and prioritizes daily workflow queues to ensure timeliness standards are met. • Identifies and reports any potential quality or fraud issues to management. • Practices professional and concise communication in writing and by phone. • 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. 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. Information Management: Ability to manage large amounts of complex information easily, communicate clearly, and draw sound conclusions. High Intensity Environment: Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow. Multi-Tasking / Time Management: Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environment. 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: Knowledge of CCN policies, processes, and procedures, knowledge of call management methodology. Working Conditions Working Conditions • Ability to cover any work shift with no travel • Works within a standard office environment • Extensive computer work with prolonged sitting and wearing of headset • VA-approved security clearance may be required Company Overview 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. Benefits 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 • Tuition reimbursement • Paid volunteer time • Annual base salary for Colorado, Hawaii, Illinois, Minnesota, Washington D.C. and Washington State residents: $47,000 - $60,000 depending on experience* Equal Employment Opportunity 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 cultivates and supports diversity at every organizational level, including hiring and retaining a diverse workforce, and we highly encourages candidates from all backgrounds to apply. Applicants are considered for positions 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.

Manage clinical operations compliance with URAC and DoD standards, oversee policy development, lead accreditation efforts, and supervise clinical audit programs. | Must have RN or LCSW license, 5+ years in healthcare quality/compliance management, 5+ years managing staff and programs, US citizenship, and ability to pass DoD background check. | Profile This is a hybrid position, mostly remote, but onsite in Phoenix, AZ occasionally. Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position. Veterans, Reservists, Guardsmen and military family members are encouraged to apply! Job Summary Manages Clinical Operations Regulatory Compliance, policy development, and program execution. This position reports to the VP Clinical Operations and coordinates with clinical operations leaders to assure URAC and T-5 Contract compliance. This position will have the responsibility to develop, implement and provide oversight of TriWest Clinical compliance program, ensuring adherence to all applicable federal, state and local regulations, as well as accreditation standards. This role focuses on maintaining the integrity of the clinical operations through robust policies, procedures, auditing and effective governance oversight. Education & Experience Required: • Current, unrestricted Registered Nurse (RN) or Licensed Clinical Social Worker (LCSW) license recognized as valid by the applicable state licensure board where the position is located • Bachelor's Degree in Nursing, Social Work, Health Care Administration or other health related field • U.S. Citizen • Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation • 5 years’ experience quality, compliance or related field in healthcare • 5 years’ experience in management of staff and programs Preferred • URAC (Utilization Review Accreditation Commission) recognized Case Manager Certification Master's Degree in Nursing or related field • Previous experience leading and managing case management or utilization management Veterans Healthcare or TRICARE Program experience • Demonstrated experience in performing analysis of utilization and quality data and with policy development and technical writing Key Responsibilities • Provides leadership to ensure compliance with URAC standards. • Directs all aspects of URAC accreditation for relevant clinical programs. • Supervises accreditation coordinators and collaborates subject matter experts related to accreditation compliance. Organizes and coordinates workflows with immediate team and related teams. Provides direction, coaching, performance management and issues resolution to team. • Ensures ongoing compliance with all URAC standards, including continuous monitoring, gap analysis, implementation. • Ensures comprehensive documentation for URAC accreditation, including policies, procedures, training records, and evidence of compliance. • Provides oversight of Clinical Operations Policy and Procedure Development and management. • Develops, reviews, revises and maintains all clinical operations policies and procedures to ensure compliance with regulatory requirements, URAC and internal best practice. • Establishes a systematic process for policy review cycles, approvals, communication and version control. • Designs, implements, and manages a comprehensive clinical auditing program to assess adherence to policies, procedures, regulatory requirements, and URAC standards. • Conducts routine and ad hoc audits of clinical operations departments, provider credentialling, appeals and grievances related to clinical operations, and special oversight programs related to quality of care delivered in the network (e.g. prescription monitoring and TRICARE Quality Monitoring Contract or TQMC). • Provides oversight and coordination of the clinical audit programs and performs analyses to measure program impact and identify opportunities to improve the effectiveness of the program to meet performance targets. • Performs annual and ongoing evaluation of the Clinical programs to ensure adherence to URAC standards, TRICARE policy, contractual requirements, HIPAA privacy and nationally recognized practice. • Develops training programs, training documents, and flow diagrams to address targeted operational issues related to compliance and audit. • 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, Excel, PowerPoint, Outlook, TriWest Intranet, the Internet, and department software applications. Delegation Skills: Provide clear performance expectations for projects and ensure adequate access to resources for completion. Independent Thinking / Self-Initiative: Critical thinker 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. Information Management: Ability to manage large amounts of complex information easily, communicate clearly, and draw sound conclusions. Leadership: Successfully manage different styles of employees; provide clear direction and effective coaching. Multi-Tasking / Time Management: Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environment. 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. Ability to plan, implement, and monitor program effectiveness and efficiency. Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment. Technical Skills: Thorough knowledge of TRICARE programs and benefits, URAC national best-practice standards; health care delivery; clinical quality assurance program metrics, utilization management, case management, managed care concepts, management reporting tools, and medical management systems; ability to perform critical, in-depth analysis of medical records for appropriateness and level-of-care determinations. Working Conditions • Works non-regular hours, as required • Works hybrid, remotely and in office, with 10% travel • Extensive computer work with prolonged sitting • Department of Defense security clearance required Company Overview 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. Benefits 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 job postings typically include a salary range, which can vary based on the specific role and location, but generally this position ranges from around $109,000 to $139,000 per year. Equal Employment Opportunity 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.

Manage escalated customer service inquiries via chat, phone, and electronic messaging, provide subject matter expertise on TRICARE benefits, support leadership with data and training, and ensure customer satisfaction in a fast-paced environment. | High school diploma or GED, U.S. citizenship, call center or TriWest customer service experience, ability to pass DoD background check, and knowledge of customer service processes. | Profile • Must Reside in Alaska** Job Summary Manages escalated and complex scenarios through chats, telephonic interaction, and electronic messaging from Customer Service Representatives, internal TriWest departments, and Defense Health Agency personnel. Provides back-up phone and payment support during periods of high inbound call volume and/or high task inventory. Works in a detailed, multi-tasked and fast-paced production environment. Education & Experience Required: • High School diploma or G.E.D. • U.S. Citizen • Must be able to receive a favorable interim and final Department of Defense (DoD) background investigation • At least one year of TriWest customer service experience or previous call center team lead experience within the last 3 years Preferred • Health plan experience in a customer service setting • Associate’s degree or health care related certification Key Responsibilities • Assigned to the Navigator call queue, provides subject matter expertise (SME) by correctly answering telephonic, electronic and chat inquiries regarding operational processes and complex customer service inquiries. • Develops and maintains TRICARE benefit knowledge, processes and procedures. Attends and masters applicable training. • Handles escalated inquiries from staff and other departments ensuring a quick and accurate resolution to maintain internal and external customer satisfaction. • Connects with other department designated SMEs as needed to ensure first call resolution. • During times of excessive inbound call volumes and/or task inventory, takes inbound or makes outbound calls depending on call volume needs. • Takes direct inbound calls from specialized populations such as BEPP, BCAC, DCAO, MMSO, DHA to resolve caller concerns or questions. • Tracks and analyzes escalation patterns to identify common issues, knowledge gaps, or process inefficiencies, sharing findings with management to drive improvements in training, policies and workflows. • Partners with the Training, Knowledge Management, as well as other departments to resolve the identified knowledge gaps by supporting leaders with tools and information to resolve concerns. • Maintains updated knowledge of software applications, on-line systems, Customer Service Representative procedures and processes. • Assists Customer Service Representative leaders in tracking learning opportunities and Navigator Support Desk utilization. • Supports the leadership teams through data and program knowledge. Coaches to correct responses but does not performance coach/lead. • Documents all communications involving customer contacts. • Coordinates complete resolution of service issues by interfacing with the TriWest Complaints & Grievance Specialists, Military and Veteran’s Services (MVS), and DHA, other departments when requested. • Consistently contributes to the achievement of department productivity and performance metrics. • 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 unique 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. 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. Information Management: Ability to manage large amounts of complex information easily, communicate clearly, and draw sound conclusions. High Intensity Environment: Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow. Multi-Tasking / Time Management: Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environment. 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: Knowledge of TriWest policies, processes, and procedures, knowledge of call management methodology. Working Conditions Working Conditions • Ability to cover any work shift with no travel • Works within a standard office or virtual environment • Extensive computer work with prolonged sitting and wearing of headset • Security clearance required Company Overview 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. DoD Statement Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position. Benefits 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 • Tuition reimbursement • Paid volunteer time • Annual base salary for Colorado, Hawaii, Illinois, Minnesota, Washington D.C. and Washington State residents: $43,000 - $55,000 depending on experience* Equal Employment Opportunity 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 cultivates and supports diversity at every organizational level, including hiring and retaining a diverse workforce, and we highly encourages candidates from all backgrounds to apply. Applicants are considered for positions 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.