Remote Claims Review Specialist – VA & TW Internal Medical & Behavioral Health Claims (Work‑From‑Home)

Who We Are: A Mission‑Driven Team Dedicated to America’s Heroes

At TriWest Healthcare Alliance, our purpose goes beyond providing health‑care services — we exist to connect the nation’s veterans, reservists, National Guard members, and their families with the comprehensive care they deserve. Since 1996, our dedicated teams have partnered with the Department of Veterans Affairs and the Department of Defense to ensure that every hero receives timely, accurate, and compassionate health‑care coverage. Our culture is built on integrity, respect, and a shared passion for service. If you are looking for a career where your daily work makes a tangible difference in the lives of those who have served, you have found the right place.

Position Overview: Remote Claims Review Specialist – VA & TW Internal Medical & Behavioral Health Claims

This full‑time remote opportunity invites experienced claims professionals to join our Claims Operations Center. You will serve as a critical link in the claim lifecycle, performing in‑depth retrospective reviews of both medical/surgical and behavioral health claims for inpatient and outpatient services. Your expertise will help ensure compliance with government contracts, accuracy in claim payment, and the identification of potential quality or fraud issues.

Key Responsibilities

• Validate claim outcomes for accuracy, ensuring that any necessary adjustments are identified and processed in a timely manner.
• Conduct comprehensive medical and behavioral health claims reviews using the latest processing guidelines, clinical criteria, and program policies.
• Cross‑check submission details against system data to confirm completeness, correctness, and compliance with contractual requirements.
• Document findings clearly and concisely, preparing case summaries that support program payment decisions.
• Identify trends, discrepancies, or emerging issues in claim data and communicate them to the appropriate stakeholders, including medical directors, peer reviewers, and quality management teams.
• Collaborate with internal and external partners—such as providers, coding specialists, and the Claims Subcontractor—to resolve complex claim inquiries.
• Maintain strict adherence to all desktop procedures, security protocols, and regulatory standards associated with government‑funded health‑care programs.
• Actively participate in continuous improvement initiatives, offering suggestions for workflow enhancements and process efficiencies.
• Provide coaching, training, or mentorship to junior staff members, fostering a culture of knowledge sharing and professional growth.
• Consistently meet or exceed performance expectations, including productivity targets, quality metrics, and attendance standards.
• Report potential fraud, abuse, or quality concerns in accordance with established escalation pathways.
• Perform additional duties as assigned to support team objectives and organizational priorities.

Essential Qualifications

• High School Diploma or GED (additional education considered a plus).
• Minimum of two years of direct claims review experience, ideally within a health‑care or managed‑care environment.
• Demonstrated knowledge of medical, institutional, and behavioral health claims processes, including CPT, HCPCS, and ICD‑10 coding systems.
• Strong written and verbal communication skills, with the ability to convey complex information clearly and professionally.
• Proficiency with Microsoft Office Suite (Word, Excel, Outlook) and the ability to learn new claim‑processing software quickly.

Preferred Qualifications & Certifications

• Experience with government‑funded claims programs (VA, DoD, TRICARE, etc.).
• Professional coding certification (e.g., CPC, CCS, or equivalent) or comparable hands‑on coding experience.
• Intermediate to advanced proficiency with Microsoft Office, especially Excel for data analysis.
• Familiarity with TriWest’s proprietary platforms such as the Clinical Decision Support Tool and the TriWest Intranet.

Core Skills & Competencies for Success

• Analytical Acumen: Ability to dissect complex claim information, spot inconsistencies, and make data‑driven decisions.
• Attention to Detail: Meticulous verification of claim details, ensuring compliance with ever‑changing regulations.
• Communication & Interpersonal Skills: Persuasive and collaborative style that builds trust with providers, peers, and leadership.
• Adaptability & Resilience: Thrive in a fast‑paced, high‑volume environment while maintaining composure and focus.
• Technical Literacy: Comfort navigating multi‑system Microsoft environments, claim‑management tools, and internet‑based resources.
• Team Orientation: Demonstrated ability to work as a cohesive unit, supporting colleagues and contributing to shared goals.
• Integrity & Ethical Judgment: Uphold the highest standards of confidentiality and ethical conduct, particularly when handling sensitive veteran data.

Career Growth & Learning Opportunities

TriWest invests heavily in the professional development of its team members. As a Remote Claims Review Specialist, you will have access to:

• Structured onboarding and continuous training programs covering advanced coding, regulatory updates, and emerging health‑care trends.
• Mentorship from seasoned medical directors, senior claims analysts, and quality management experts.
• Opportunities to pursue further certifications (e.g., Certified Professional Coder, Certified Claims Analyst) with tuition reimbursement support.
• Pathways to advance into senior analyst, team lead, or supervisory roles within the Claims Operations Center.
• Cross‑functional project involvement, such as process redesign, fraud detection initiatives, and technology implementation teams.

Work Environment & Culture

Although this role is fully remote, you will be an integral part of a vibrant, purpose‑driven community. We provide:

• A secure, private workspace requirement with high‑speed internet to ensure confidentiality and efficiency.
• Flexible scheduling options, including the ability to cover various shifts and overtime when needed.
• A collaborative digital workplace equipped with video conferencing, instant messaging, and shared documentation platforms.
• Regular virtual team‑building events, wellness programs, and recognition initiatives that celebrate both individual and collective achievements.
• An inclusive, diversity‑focused culture that values the unique perspectives of veterans, military families, reservists, and civilians alike.

Compensation, Perks & Benefits

We offer a competitive salary range that reflects your experience and geographic location, alongside a comprehensive benefits package designed to support your health, financial security, and personal growth.

• Medical, Dental, and Vision Coverage – With multiple plan options to suit your needs.
• Generous Paid Time Off (PTO) – Including vacation, sick leave, and paid holidays.
• 401(k) Retirement Savings Plan – Company match to help you build a secure future.
• Short‑Term and Long‑Term Disability, Life Insurance, and AD&D – Comprehensive protection for you and your loved ones.
• Tuition Reimbursement – Invest in further education or professional certifications.
• Paid Volunteer Time – Encourage community involvement and giving back.
• Performance‑Based Pay Increases & Overtime Opportunities – Rewarding dedication and high performance.
• Access to employee assistance programs, wellness resources, and mental‑health support.

Equal Opportunity Employer Statement

TriWest Healthcare Alliance is proud to be an Equal Employment Opportunity employer. We celebrate diversity and are committed to creating an inclusive environment where all employees feel respected, valued, and empowered to thrive. Applications are considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other legally protected characteristic.

Application Process – Simple, Straightforward, and Fast

Ready to make a meaningful impact? Follow these easy steps:

1. Click the “Apply Now” button below to submit your resume and a brief cover letter highlighting your relevant experience.
2. Our recruiting team will review your application within 48 hours and reach out to schedule a virtual interview.
3. Participate in a structured interview process, including a skills assessment relevant to claims review.
4. Upon successful completion, you will receive a formal offer and begin your onboarding journey.

We look forward to welcoming you to our mission‑driven family and working together to serve those who have served our nation.

Apply Now

Take the first step toward a rewarding remote career with TriWest Healthcare Alliance. Apply To This Job today!