Registered Nurse - Utilization Manager

Decypher • Wright-Patterson AFB, OH

1d

About The Position

Decypher is hiring a Registered Nurse - Utilization Manager to support the Defense Health Agency and help deliver quality care to service members, veterans, and their families. The role develops and implements a Utilization Management program aligned with Military Treatment Facility, Air Force, and Defense Health Agency goals. It reviews medical necessity and clinical utilization, monitors referrals, analyzes program data, and coordinates discharge planning and care-management activities.

The position requires an associate or bachelor's degree in nursing, Basic Life Support certification, an active unrestricted Registered Nurse license, and qualifying discharge-planning or case-management experience. U.S. citizenship is required. The position is full-time and scheduled Monday through Friday for eight-hour shifts, from 7:00 a.m. to 4:30 p.m., including a 30-minute uncompensated lunch. Compensation is $44.92 per hour, plus H&W if applicable.

The work involves reviewing medical records and using a computer, with frequent use of standard office equipment and verbal and written communication. It requires attention to detail and sufficient visual acuity to analyze clinical documentation, as well as occasional movement around the workplace and lifting up to 10–15 pounds.

Requirements

• Associate degree (ADN) or Bachelor of Science in Nursing (BSN) from a program accredited by a national nursing accrediting agency recognized by the U.S. Department of Education.
• Basic Life Support (BLS) certification.
• Valid, active, unrestricted Registered Nurse license.
• Discharge-planning or case-management experience: 4 years for ADN holders or 2 years for BSN holders.
• Full-time employment in a nursing field within the last 36 months.
• U.S. citizenship.

Responsibilities

• Assist with inpatient discharge planning, including home-safety patient and family interviews, morning planning meetings, and coordination of transfers, durable medical equipment, home care, inpatient rehabilitation, and skilled care.
• Develop and implement a comprehensive Utilization Management program aligned with MTF, Air Force, and DHA goals and objectives.
• Collect, analyze, and trend program data and metrics to identify over- or underutilization of healthcare resources, inefficiencies, and cost-containment opportunities.
• Provide timely reports, feedback, and recommendations.
• Monitor specialty-care referrals for appropriateness, covered benefits, and authorization of medical procedures, laboratory, radiology, and pharmacy services.
• Evaluate clinical practice patterns and trends and provide feedback to the Chief of Hospital Services (SGH) and clinical teams.
• Identify and refer potential cases to Disease Management, Case Management, Discharge Planning, and the Deployment Availability Working Group.
• Participate in Medical Management, Population Health Working Group, and care-coordination meetings as assigned.
• Conduct nursing peer reviews as assigned.
• Educate Patient-Centered Medical Home (PCMH) staff about the role of Utilization Management.
• Assist the PCMH team in notifying patients admitted to civilian hospitals or civilian emergency departments.
• Perform medical-necessity reviews, including concurrent length-of-stay reviews using approved clinical decision tools.
• Assess the medical necessity of services and communicate negative trends to the Chief of the Medical Staff.
• Navigate electronic health records and TRICARE managed-care contractor sites.
• Act as referral approval authority for designated referrals under MTF, Air Force, and DHA national guidance and standards.
• Process and validate durable medical equipment referrals for PRIME beneficiaries and authorize Supplemental Health Care Program (SHCP) funds for active-duty beneficiaries.
• Refer first-level review failures to SGH or designated points of contact for further review and disposition.
• Verify beneficiary eligibility using the Defense Eligibility Enrollment Reporting System (DEERS).
• Obtain pertinent patient information and update electronic medical records, local referral databases, and other office automation systems as needed.
• Perform other duties as assigned.

What This Job Offers

• Job Type: Full-time
• Education Level: Associate degree