Registered Nurse - Utilization Management

Duties: The duties include, but are not limited to the following;

• Assist with orientation and training of other Medical Management staff and assist in providing, assessing, and improving a wide variety of customer service relations. Assists MTF officials to ensure Unit Effectiveness Inspection standards are met at the operational level.
• Assists in the development and implementation of a comprehensive Utilization Management plan/program for beneficiaries within MTF’s goals and objectives. This plan is based on using the 12-step approach as described in the DoD Medical Management Guide.
• Establish procedures for conducting reviews, including identification of types of healthcare services for which preauthorization or concurrent review will be required. Reviews previous and present medical care practices as needed for patterns, trends, or incidents of under or over utilization of hospital resources incidental to medical care provided to beneficiaries.
• Plans and performs reviews IAW established indicators and guidelines to provide quality cost-effective care. Ensures identified patient needs are addressed promptly with appropriate decisions. Provides timely, descriptive feedback regarding utilization review issues. Use the same generally accepted standards, norms, and criteria to review the quality, completeness, and adequacy of healthcare provided within the MTF, as well as its necessity, appropriateness, and reasonableness.
• Adhere to the established standardized DCS appeal process for resolving beneficiaries’ request for reconsideration of MTF denials of care based on medical necessity determinations in accordance with References (e) and (o). After following the directed methodology for appeals, the MTF will also adhere to its respective Service or joint commands’ process for intermediate notification, if any, prior to progressing from the internal to external level of appeals.
• Adhere to the MHS and Military Department’s or Joint Medical Commands’ referral management policies to manage internal and external referrals. Incorporate UM strategies as part of the referral management center’s routine processes. Ensure processes monitor, manage, and optimize demand or capacity (access).
• Collaborate with the PCMH team to develop performance measures and processes for clinically important conditions, as determined by the PCMH teams and MTF leadership. These clinically important conditions should include but may not be limited to high -cost, high-volume, or problem-prone diagnoses, procedures, services, and beneficiaries that utilize healthcare at higher rates than average and who may benefit from intervention and more intense care coordination. Performs data/metric collection. Analyzes data and prepares reports to describe resource utilization patterns. Briefs applicable data/slides to provider staff, executive staff, newcomers, as appropriate. Identifies areas requiring intensive management or areas for improvement.
• Maintains reports on which cases have been denied or received reduced third party payments and reports provider profiles to the MTF management for corrective action.
• Serves as a liaison with higher headquarters, TRICARE Regional Office, MTF national accreditation organization, professional organizations, and community health care facilities concerning Utilization Management.
• Participates in in-services and continuing education programs. Briefs applicable data/slides to provider staff, executive staff, newcomers, as appropriate.
• Establishes and maintains good interpersonal relationships with co-workers, families, peers, and other health team members. Submits all concerns through Utilization Management Director; be able to identify, analyze and make recommendations to resolve problems and situations regarding referrals. Ensure coordination and communication among all MM staff, including clinical and business personnel, to assure efficient, effective, quality care and services.
• Be productive and perform with minimal oversight and direction. Be able to independently identify, plan, and carry out projects with consideration for the goals and objectives of the TRICARE Utilization Management Element. Develops detailed procedures and guidelines to supplement established administrative regulations and program guidance. Recommendations are based upon analysis of work observations, review of procedures, and application of guidelines.

Schedule:

Monday - Friday, 9 hours between 7:00am and 5:00pm, with a one-hour lunch

No Weekends or Holidays

Minimum Qualifications:

* Education: Minimum ASN from an accredited college or university
* Experience: One year of experience in Utilization Management is required. Full time employment as a registered nurse within the last 36 months is mandatory. Six years of clinical nursing experience is preferred. 
Must possess experience in performing prospective, concurrent, and retrospective reviews to justify medical necessity for medical care to aid in collection and recovery from multiple insurance carriers. Review process includes Direct Care and Purchase Care System referrals, ward rounds for clinical data collection, contacting providers to inform them of dollars lost for missing documentation, and providing documentation for appeals resolution.  Possesses working knowledge of Ambulatory Procedure Grouping (APGs),Diagnostic Related Grouping (DRGs), International Classification of Diseases-Version 9(ICD), and Current Procedural Terminology-Version 4 (CPT-4) coding.

* Licensure: Current, full, active, and unrestricted RN license from any state.

* Life Support Certifications: AHA or ARC BLS Certification 
* Security: Must possess ability to pass a Government background check/security clearance.

We are an equal opportunity employer and a drug free workplace. All applicants selected for employment are required to submit to a background check and pre-employment drug test. 

Excellent Compensation & Exceptional Comprehensive Benefits:

* Paid Vacation, Paid Sick Time, Plus 11 Paid Federal Holidays! 

* Medical/Dental/Vision, STD/LTD/Life, Health Savings Account available, and more!
* Annual CME Stipend and License/Certification Reimbursement!

* Matching 401K!

Base salary: $32.00 - $44.00/hr depending on experience