Clinical Nurse Utilization Manager (RN)

ERP International•Montgomery, AL

6d•Onsite

About The Position

ERP International is seeking a Clinical Nurse (RN), Utilization Manager for a Full-Time position in support of the 42 Medical Group at Maxwell AFB, AL. This role involves using data-driven processes to identify and improve the delivery of care and resource utilization within the Medical Treatment Facility (MTF). The position requires collaboration with provider staff, executive staff, and MTF officials to ensure high-quality, cost-effective care and adherence to Health Service Inspection standards. The Utilization Manager will leverage clinical decision support tools, maintain reports on denied or reduced payments, and educate MTF staff on referral processes and appropriate care levels. Responsibilities also include notifying PCM teams of patient status changes, conducting discharge planning, assisting in the development of a comprehensive Utilization Management plan, and serving as a liaison with various healthcare entities.

Requirements

Bachelor’s degree of Nursing.
Graduate from a college or university accredited by Accreditation Commission for Education in Nursing (ACEN), the Commission on Collegiate Nursing Education (CCNE) Incumbent degree may be considered if lower than required.
At least 24 months of full-time experience within the last 36 months in Utilization Management.
Current, full, active, and unrestricted license to practice as a Registered Nurse.
Possess current ARC or AHA BLS Healthcare Provider certification.
Must possess ability to pass a Government background check/security clearance.

Responsibilities

Uses data-driven processes to prospectively and retrospectively identify indicators of ineffective or inefficient delivery of care and to describe MTF resource utilization patterns. Briefs applicable data/slides to provider staff, executive staff, newcomers, as appropriate.
Plans and performs reviews IAW established indicators and guidelines to provide high-quality, cost-effective care. Assist MTF officials to ensure Health Service Inspection standards are met at the operational level.
Leverage evidence-based clinical decision support tools to determine the appropriate level of care and improve resource utilization.
Maintain reports on which cases have been denied or received reduced third-party payments and reports provider profiles to the MTF management for corrective action as needed.
Educates MTF staff on the referral process and tools available to determine appropriate level of care to achieve optimal patient outcomes. Identify, analyze and make recommendations to resolve problems and situations regarding referrals.
Notifies the PCM team of known admissions, discharges, and emergency room/urgent care clinic visits. Conducts discharge planning IAW accrediting agency standards for all eligible beneficiaries.
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 described in the DoD Medical Management Guide.
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.
Participate in MTF Medical Management, Population Health, Quality, and Care Coordination meetings to ensure alignment and integration of UM activities and promote MTF health strategies.