Registered Nurse - Utilization Management
Full Time
Hurlburt Field, FL 32544
Posted
Job description
Registered Nurse (RN) – Utilization Management
Hurlburt Field, FL
Position Duties and Responsibilities:
- Develops and implements a comprehensive Utilization Management plan/program in accordance with the facility’s goals and objectives.
- Performs data/metrics collection on identified program areas; analyzes and trends results, including over- and underutilization of healthcare resources. Identifies areas for improvement and cost containment. Reports utilization patterns and provides feedback in a timely manner.
- Analyzes medical referrals/appointments and general hospital procedures and regulations by monitoring specialty care referrals for appropriateness, covered benefits, and authorized surgery/medical procedures, laboratory, radiology and pharmacy.
- Performs medical necessity review for planned inpatient and outpatient surgery; and performs concurrent review to include length of stay (LOS) for the facility’s inpatients using appropriate criteria.
- Reviews previous and present medical care practices for patterns; trends incidents of under-or over-utilization of resources incidental to providing medical care.
- Acts as referral approval authority for designated referrals per local/AF/DoD/national guidance and standards. Refers all first-level review failures to the SGH or other POC for further review and disposition.
- Verifies eligibility of beneficiaries using Defense Eligibility Enrollment Reporting System (DEERS). Obtains pertinent information from patients/callers and updates data in CHCS, AHLTA, local referral database, and other office automation software programs as appropriate and directed.
- Ensures and monitors specialty care referrals for appropriateness, medical necessity, and if the appointment, diagnostic testing, or procedure requested is a covered benefit according to appropriate health plan. If unsure, coordinates with TRICARE Regional Office Clinical Liaison Nurse or reviews TRICARE Operations Manual.
- Receives and makes patient telephone calls, written, or e-mail correspondence regarding specialty clinic appointments and referrals following MTF-specific processes.
- Routinely monitors referral management Composite Health Care System (CHCS) queue to ensure patients referrals are appointed and closed out.
- Ensures Line of Duty paperwork is on file prior to authorization for all reserve and guard member referrals.
- Keeps abreast of MTF and local market services and capabilities. Updates capability report as needed/directed.
- Conducts referral reconciliation report as directed, identifying all open referrals and provides notification to appropriate personnel for resolution.
- Monitors active duty, reserve/guard admissions to civilian hospitals and notifies Case Manager and Patient Administration Element as required.
- Serves as a liaison with headquarters, TRICARE regional offices, MTF staff and professional organizations concerning Utilization Management practices.
- Collaborates with staff/departments, including, but not limited to: Executive Management, Resource Management, Medical Records, Patient Administration, Group Practice Managers, Health Care Integrators, Coders/Coding Auditors, Population Health Nurse Consultants, Medical Management, Referral Management, TRICARE Operations, patient care teams, Quality Improvement, and the Managed Care Support Contractors.
- Coordinates and participates in interdisciplinary team meetings, designated facility meetings, and Care Coordination meetings. Shares knowledge and experiences gained from own clinical practice and education relevant to nursing and utilization management.
- Participates in the orientation, education and training of other staff. May serve on committees, work groups, and task forces at the facility. May serve as a member of the Prime Service Area Executive Council (PSAEC).
- Must maintain a level of productivity and quality consistent with: complexity of the assignment; facility policies and guidelines; established principles, ethics and standards of practice of professional nursing; the Case Management Society of America (CMSA); American Accreditation Healthcare Commission/Utilization Review Accreditation Commission (URAC); CAMH; (AAAHC); Health Services Inspection (HSI); and other applicable DoD and Service specific guidance and policies. Must also comply with the Equal Employment Opportunity (EEO) Program, infection control and safety policies and procedures.
- Follows applicable local MTF/AF/DoD instructions, policies and guidelines.
- Completes medical record documentation and coding, and designated tracking logs and data reporting as required by local MTF/AF/DoD instructions, policies and guidance.
- Completes all required electronic medical record training, MTF-specific orientation and training programs, and any AF/DoD mandated Utilization Management training.
Minimum Qualifications:
- Bachelors of Science in Nursing.
- Graduate from a college or university accredited by National League for Nursing Accrediting Commission (NLNAC), or The Commission on Collegiate Nursing Education (CCNE).
- Minimum of one year of experience as a Registered Nurse.
- Current, full, active, and unrestricted license as a Registered Nurse.
- Must be a US Citizen.
Potomac Healthcare Solutions offers the following benefits:
- Medical, Dental and Vision Insurance
- Health Savings Account
- Employer Paid - Basic Life, Accidental Death & Dismemberment and Short-Term Disability
- Long Term Disability
- 401(k) Retirement Savings Plan
- Paid Time Off
- 10 Federal Holidays
- Continuing Education
- Employee Assistance Program
- Wellness Incentives and More
About Potomac Healthcare Solutions:
Potomac Healthcare Solutions is an award-winning, dynamic, and rapidly growing healthcare services company with a proven background in providing world-class health services for both government and commercial organizations. We are actively recruiting skilled, caring practitioners to support our rapidly growing program base and supported healthcare facilities. If you would like to be a part of a quality-driven organization and make a difference, we would like to talk to you!
If you do not find interest in this opportunity but know of someone who may, we kindly ask that you refer the individual to Potomac Healthcare Solutions by forwarding this job posting.
We especially welcome employment interest of US Military Veterans with honorable service.
Potomac Healthcare Solutions, LLC is an Equal Opportunity Employer Veterans/Disabled.
***This position is contingent upon contract award.
learninglandscape.com is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, learninglandscape.com provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, learninglandscape.com is the ideal place to find your next job.