Licensed Practical Nurse (LPN) – JB Charleston, SC

Reef Systems • Charleston, SC

8d • Onsite

About The Position

Reef Systems has an immediate need for a Licensed Practical Nurse (LPN) to support the Air Force Medical Service (AFMS) mission at the Referral Management Center (RMC) located at JB Charleston, SC. This is a full-time, on-site position. The Air Force Medical Service (AFMS) operates and manages a worldwide healthcare system to deliver medical service for beneficiaries including active duty, family members, and retirees. The AFMS responds to health requirements and provides an integrated healthcare system with an emphasis on prevention of illness and injury. Referral Management (RM) is a critical process where the Referral Management Center (RMC) advises patients of their benefits, works with referring providers and the Managed Care Support Contractor (MCSC) to ensure referral accuracy, coordinates referrals with specialty offices, facilitates the recapture of Medical Treatment Facility (MTF) direct care capabilities, tracks referrals to closure, and returns all results of treatment to the patient’s medical record. The RMC serves as the central clearing house for providers and patients needing information or help with referrals. The Contractor shall support the AFMS’ mission of staffing and managing RMCs at the MTFs, serving as the one-stop shop for all referrals from initiation to receipt of a HIPAA-compliant report.

Requirements

• Shall read, understand, speak, and write English fluently.
• Shall have knowledge, skills and computer literacy to interpret and apply medical care criteria, such as, but not limited to, InterQual or Milliman Ambulatory Care Guidelines.
• Shall have a minimum of two (2) years broad-based clinical nursing experience in either an inpatient or outpatient care setting within the last three (3) years.
• License must be valid and unrestricted.
• Contract personnel shall be in good standing, and under no clinical restrictions, with the licensure boards in all jurisdictions in which a license is held or has been held within the last ten (10) years.
• Operational computer skills with general working knowledge of word processing, and Microsoft applications (including Windows, Word, Excel, Outlook).
• General medical ethics, telephone etiquette, written/verbal/electronic communication, and customer service skills.
• Proof of immunization for hepatitis B, influenza, measles, mumps, rubella, varicella, Tdap, influenza.
• Proof of a negative TB skin test completed within the past twelve (12) months (if positive, proof of negative chest X-ray within the past twelve (12) months).
• Maintain current certification in the American Heart Association Basic Life Support (BLS) (Course C) or the American Red Cross CPR/BLS (Heart Saver) Course.
• Obtain initial training at no cost to the Government prior to duty start date so that RMC personnel arrive in their positions fully qualified.

Nice To Haves

• The Government may offer refresher training for RMC personnel on a space-available basis.
• The Government will provide initial on-the-job (OJT) training on Government provided forms and equipment, initial orientation, and annual training requirements specific to the MTF.
• The Government will also provide initial training, within five (5) business days of task order award, to the Contractors’ education and training department for subsequent Contractor training (“train the trainer”)

Responsibilities

• Operate the RMC at the MTFs listed within Appendix A, supporting RMC operations and providing referral management services to patients during normal MTF business hours for telephonic, electronic, and in-person access.
• Process and review referrals in Government information systems including, but not limited to: MHS GENESIS, the Composite Health Care Suite (CHCS), MCSC referral systems, Armed Forces Health Longitudinal Technology Application (AHLTA), Health Artifact Imaging & Management System (HAIMS), and Referral Management System (RMS) Integrated Clinical Database-B (ICD-B) programs.
• Accurately refer patients to subsequent care using the most current MTF Capabilities Report, and the Access to Care (ATC) standards and RMC Business Rules as outlined in Air Force Instruction AFI44-176 and in the AFMS Referral Management Center Guide – version 9.0, Attachment 1 of the PWS.
• Initiate, follow, manage, and close all referrals within timeliness standards identified in the TRICARE Operations Manual, the RMC business rules, and other current Government policies, regulations, and memorandums.
• Provide patient education including, but not limited to, specialty care referral, procedures, and labs to prepare the patient for their specialty care appointment and/or procedure.
• Provide MTF clinical personnel education concerning referral process and timelines, no less than semi-annually, utilizing education opportunities during training venues to include provider/nurse orientation briefings and Professional Staff (ProStaff) meetings.
• Identify and notify the Government MTF case manager, Utilization Management (UM) nurse or Primary Care Management (PCM) team, as appropriate, of any patient that may benefit from or may require care management/coordination.
• Sustain and follow the most current MTF Specialty Clinic Booking Guidance, MTF Capabilities Report and MTF/MCSC Memorandums of Understanding to maximize recapture initiatives and enhancements.
• Participate in inspections by providing any requested referral management information by inspectors.
• Review initial specialty care and deferred-to network primary care referrals for administrative completeness, covered TRICARE benefit, and required tests and pre-work. Coordinate with referring providers in cases where additional referral information is required.
• Verify patients are registered in CHCS and Defense Enrollment Eligibility Reporting System (DEERS); update demographic and other pertinent information through the appropriate medical systems and software programs. Obtain current and accurate contact information.
• Determine patient eligibility for services and schedule specialty referral appointments to MTF or Other Direct Care System (ODCS) using CHCS booking procedures, ATC standards, and established clinic capability/booking protocols. If there are no MTF or ODCS referral appointments within ATC standards, the RMC shall defer the referral to the network through the MCSC.
• Assist with ROFR determinations for specialty care that can be provided within the MTF using service availability (capability) listings and information systems that link the referral to the appointment with the ATC category and standard.
• Document patient appointments in the approved AFMS system(s), such as but not limited to CHCS, the RMS, and ALTHA. Enter ROFR-type referrals into CHCS for review and appointments.
• Process ROFRs within the time limits outlined in the TRICARE Operations Manual, Chapter 8, Section 5 (or as amended).
• Accept/decline urgent priority ROFRs and outside referral requests received within thirty (30) minutes of receipt.
• Accept/decline routine priority ROFRs and outside referral requests received within one (1) business day of receipt.
• Return completed referrals submitted by network/VA provider’s specialty care referral results (ROFR results) to the referring purchased care provider within ten (10) business days of the kept specialty encounter.
• Verify that referrals are activated within the referral priority standards (Routine, Emergent, and Urgent). RMC staff shall assist with appointing/activating referrals and providing customer support to patients as outlined in the latest AFMS RMC Business Rules.
• Correct inaccurate authorizations in the RMS.
• Coordinate with specialty referral clinics on special patient instructions and tests required prior to appointment.
• Provide pre-appointment instructions to patients, if possible, prior to leaving the MTF. Advise patients of the provider, location, time, and day of referral appointments or request the patient to call back for appointment information if patient not provided appointment prior to leaving the MTF. Include care episode information for the referral provider as to where to return referral results.
• Contact and inform patients in the event referral requests are invalid (e.g., non-covered benefits) or disapproved by MTFs second level reviewer or MCSC. Reschedule or instruct patient of other health care options within two (2) business days of notification of referral being invalid or disapproved by the second level reviewer.
• Submit referrals to the appropriate reviewer when required for medical necessity and appropriateness review.
• Utilize the referral naming convention in Telephone Consults (T-Cons), AHLTA clinical notes and HAIMs, or additional systems, as outlined in the latest AFMS RMC business rules.
• Return all calls within two (2) business days.
• Monitor the secure messaging box three (3) times a day for messages. Follow-up with patients and/or direct messages to the PCM team accordingly.
• Generate and forward referral-related patient telephone consults requiring clinical decision-making to the appropriate provider/team.
• Review TRICARE Regional Office reconciliation/summary report daily; identify all open referrals and ensure resubmission.
• Track and obtain initial specialty care and deferred to Network primary care referrals to include obtaining CLRs from MTF, ODCS, network, and non-network providers. When follow-up results are received from specialists, ensure they are sent to the referring provider or PCM.
• Retrieve CLRs no later than (NLT) (180) calendar days after the order entry date. If the RMC does not receive the CLRs within (180) calendar days, the Contractor is responsible for researching (chasing) and expeditiously retrieving CLRs as outlined in the latest AFMS RMC business rules.
• Import/scan CLRs into the correct patients’ medical record within three (3) business days from receipt of results from consulted provider/specialist and return CLR results to the referring provider or PCM within three (3) business days of receipt from the consulted provider/specialist as outlined in the TRICARE Operations Manual and AFI 44-176 Attachment 2, RMC business rules.
• Follow-up with MTF specialty care providers who did not complete CLR referral results in accordance with AFMS RMC business rules.
• Provide the referring providers a monthly list of their referred patients who have not scheduled their initial specialty care appointment for the referring provider/team’s action.
• Provide initial results of all referrals written by the MTF. Send all referrals to the referring provider/PCM for review to be tracked and closed.
• Prepare referral management data reports/metrics, using referral tracking data tools. Reports and metrics will be as determined by the latest AFMS RM Business rules, local MTF policies and procedures, as well as any regulatory guidance currently in effect. Accuracies shall be completed within three (3) business days.
• Accurately advise all patients of their referral eligibility, beneficiary status, and health treatment options as outlined by their TRICARE enrollment and/or DEER status.
• Coordinate with MTF Chief of Medical Staff (SGH) for all active, reserve, and guard referrals not covered under the TRICARE benefit for approval.
• Direct patient to patient travel coordinator and provide information on travel related benefits.
• Assist MTF, as necessary, on advising patients regarding Line-of-Duty, Personal Reliability Program (PRP), and Medical Evaluation Board issues. Verify appropriate paperwork is on file prior to authorization.
• Provide medical ethics, telephone etiquette, office, administrative, and clerical skills to perform receptionist duties. Provide positive, courteous, and professional customer service support to patients and MTF staff.
• Initiate, receive, and coordinate (telephone/computer/written) communication between beneficiaries, team members, internal staff and providers, network/outside providers and ancillary health care workers regarding specialty clinic appointments and referrals.
• Resolve substantiated complaints within five (5) business days of receipt of complaint.

Benefits

• The MTF will not provide immunizations or tests for individuals not entitled to medical care.
• The MTF will not perform any medical tests or procedures required by the contract for non-beneficiaries except in the rare case of post-exposure in accordance with Air Force, DoD, and CDC guidelines or recommendations.
• If RMC personnel receive training within the facility, the time spent in the training course will not be billable to the Government.
• The Government will not pay for recertification training obtained outside the MTF.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed