Job: Manager, Referral Management

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Jobing Description

Job Summary

Responsible for the referral and authorization processing operations to meet Department of Defense (DoD) Contract standards in a production environment. The Hub Referral Manager (HRM) is responsible for quality and training of Beneficiary Service Representatives for all aspects of data entry including, but not limited to medical terminology, medical coding, and interpretation of written diagnoses and clinical conditions. Collaborates with and provides support to TriWest Customer Service/Contact Center, Vice Presidents of Operations, Provider Services, Service Area Directors, Field Clinical Coordinators (FCCs), Clinical Liaison Nurses (CLNs) at each Military Treatment Facility (MTF), MTF Referral Management Center staff, Medical Management Support Office (MMSO), and TRICARE Regional Office (TRO) to promote superior customer service and ensure operations meet production and quality standards.
Reports to Director of Referral Management and Vice President of Hub Clinical Operations.
Key Responsibilities

o Manages Referral Management department operations to achieve desired outcomes, including developing and executing strategies for achieving TriWest's contract requirements. This includes daily communication with HCS Hub leadership to coordinate resources. Monitors Referral Management department's performance outcomes, drives training needs, identifies process improvement opportunities, and resolves issues negatively impacting department performance and outcomes. Identifies ways to improve service levels through effective production management.
o Manages Human Capital-related activities for the Referral Management department, including recruiting, coaching, and developing supervisors and staff.
o Manages and monitors training, including department-specific and on-the-job training components. Along with team coordinator, provides staff refresher training, one-on-one training, and assists the Director Referral Management with leadership development training. Works with Leadership Development and Training (LD&T) to update existing classes and adds classes as necessary. Coordinates quality and improvement of R/A activities.
o Collaborates daily with Director Referral Management, HRMs, Hub Clinical Directors and Hub Clinical Managers to problem solve Hub referral management/prior authorization or utilization management issues, reporting significant issues to upper management.
o Serves as primary clinical resource for Field Operations Clinical Liaison Nurses (CLN) and Service Area Directors (SAD).
o Provides clinical support and interpretation assistance to non-clinical staff for both medical/surgical and behavioral health conditions.
o Develops and implements enhanced systems and processes to improve Hub operational performance metrics and delivery of care. Monitors ongoing compliance with contract standards for timeliness and quality. Collaborates with staff for data compilation and statistical analysis.
o Participates in cross-functional teams to enhance business strategies, process improvement, and use of industry best practices.
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o Collaborates with Congressional and Customer Relations teams to improve delivery of TRICARE services. Assists with TMA and TRO-W inquiries regarding service levels. Collaborates with Field Operations and Provider Services peers to ensure continuity of care for beneficiaries and to identify areas for process improvement.
o Drives continuous enhancements for referral and authorization processing as the subject matter expert for emerging medical management system technology.
o Assists the Vice President Operations with orienting visiting dignitaries, MTF and TRICARE Regional Office West (TRO-W) representatives, as needed.
o Assists Director Referral Management in managing annual Referral Management department budget.
o Performs other duties as assigned.

Skills / Requirements

Education & Experience

Required:
o Registered Nurse with current unrestricted license
o Bachelor's Degree in Nursing, Health Administration or related field
o Two years or more of supervisory or managerial experience
o Five years clinical experience
o Managed care and operational experience in medical management systems, including referral management/prior authorization or utilization management
Preferred:
o Two years or more experience in a production environment
o Experience with TRICARE Program
o Knowledge of Military Health System (MHS)
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.
High Intensity Environment: Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.
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: Thorough knowledge of health care delivery, clinical quality assurance program development and metrics, managed care concepts, management reporting tools, and medical management systems; ability to perform critical, in-depth analysis of medical records for appropriateness and effectiveness of R/A activities

DoD Statement

You are applying for a position that involves working on electronic systems that have access to Department of Defense ('DoD') systems. Therefore, you must undergo a DoD background investigation. This requires you to submit an application describing the previous 7 years of your life and to provide proof of U.S. citizenship in the form of a certified birth certificate, certificate of naturalization, current passport, form FS-240 or form DS-1350. This process takes several months to complete. During this time, the DoD will grant interim access to U.S. citizens allowing them to work for TriWest until their background investigation is completed. However, the DoD will not authorize interim access for non-U.S. citizens. If you are unable to obtain interim access or pass the background investigation, you are not qualified for this position and TriWest will withdraw any offer of employment or terminate your employment immediately.