RN - Utilization Management

Matrix Providers•Bethesda, MD

1d•Onsite

About The Position

Matrix Providers is hiring a Registered Nurse Utilization Management to join our team of talented professionals who provide health care services to our Military Service Members and their families in at Walter Reed National Military Medical Center Bethesda, Maryland . Employment Status: Coverage Position Schedule: Registered Nurse Utilization Management services are required Monday through Friday between the hours of 0730 and 1630. The Registered Nurse Utilization Management must have and meet the following: Degree/Education : Degree or diploma for a professional nursing program approved by the legally designated State accrediting agency. Active current registration as a professional nurse in a State, District of Columbia, or a territory of the United States. Certification : Basic Life Support for Healthcare Providers, American Heart Association, or American Red Cross Healthcare Provider Course. Legal Authorization to Work in the United States : The contract worker performing under this contract must be a U.S. Citizen Registered Nurse Utilization Management Core Job Duties: This Registered Nurse will provide Referral Management (RM) activities including but not limited to the following: Timely processing of Right of First Refusal (ROFR) requests, screening of specialty care referrals, sustaining up-to-date Specialty Clinic Booking Guidance, MTF Capabilities Report, ROFR Reports, maintaining up-to-date MTF/Managed Care Support Contract (MCSC) Memorandums of Understanding (MOUs), comply with Referral and Authorization Business rules, tracking, accounting, and resulting of referrals, and full use of RM information management systems. Individual will conduct reviews for medical necessity, preauthorization, medical appeals, collection and recovery from insurance carriers, and right of first refusal activities. Knowledge of sources for patient care data. Examples are: medical records via ESSENTRIS and CHCS, 24 hour nursing reports, logs, consults and computerized data, RMS. Knowledge of sources for patient care data. Examples are: medical records via ESSENTRIS and CHCS, 24-hour nursing reports, logs, consults, and computerized data, Case Management Dashboard. Maintenance of RN License requirements/certifications, availability for random drug tests, Physical, Security and any other WRNMMC Policy adherence. Ability to read, write, speak and understand English well enough to effectively communicate with all patients and other health care providers. Be a U.S. Citizen. Knowledge of equipment and supply terminology and possess skills sufficient to identify and use necessary equipment and supplies properly and to communicate proper use with nurses, medical staff, patients, and family members. Be sufficiently skilled to teach patients proper self-care and to motivate patients and family members to continue the procedures for promoting rapid healing. Shall be knowledgeable and possess skills necessary to provide care appropriate to any age-related needs of the patients. Knowledge of the principles of growth and development appropriate to the patient population served: Infants, Children, Adolescents, Adults, and Geriatrics (>65). Knowledge of a wide range of medical disorders/conditions, diagnostic studies and treatments related to prevention, and detection of illnesses in adults, is desirable. Knowledge in professional care theories, principles, practices, and procedures to perform nursing assignments of moderate difficulty and experience in assessing adult and geriatric patients, as appropriate. Knowledge of computer operations and possess proficiency in the use of basic word processing, data entry and automated medical records. Ability to function as a member of a multidisciplinary team in the coordination of patient care and outcomes. Possess excellent oral communication skills for patient/family education, and excellent written communication skills to perform accurate documentation, both written and electronic, of all activity in accordance with requirements. Knowledge of a variety of pharmacological agents used in patient treatment, the desired effects, side effects, and complications of their use as well as the accurate administration of the pharmacologic agent, including dosage calculations as required. Knowledge of administrative requirements for the documentation of patient's condition, progress and acknowledgement of teaching, and follow up care. Possess good time management skills. Ability to facilitate continual patient-centered and outcome driven health performance improvement initiative by reviewing, processing and providing appropriate disposition of referrals that may involve coordination of clinical care and services for active duty services members, family members, and retirees covered by the Tricare Prime insurance benefit. Clinical subspecialty experience in Behavioral Health (2-5 years current experience). Referral Management/Utilization Management (RM/UM) experience. Unique Military Healthcare System/Procedures: Essentris Armed Forces Health Longitudinal Technology Application (AHLTA) (MHS Genesis) formally known as the Armed Forces Health Longitudinal Technology Application (AHLTA). Contractor HCP shall attend training in the use of MHS Genesis. Defense Enrollment Eligibility Reporting System (DEERS) Provide professional case management services at Walter Reed National Military Medical Center (WRNMMC) or Fort Belvoir Community Hospital (FBCH). Functions as a member of a multidisciplinary team to meet individual and family comprehensive health needs. Duties involve planning, coordinating, facilitating, and evaluating health care, serving as an advocate for patient options and services. Utilizes communication and available resources to promote quality and cost-effective outcomes, across the continuum of care. Serves as a clinical case manager and patient advocate, providing advanced practice clinical, administrative, and organizational skills in managing the continuity, access, and provision of care services for complex and defined patients, to include catastrophic and end-of-life patient populations. Responsible for identification and management of patients with targeted, high risk and high cost diagnoses. Independently performs difficult and complex assessment, review, coordination, planning, monitoring, evaluation and analysis of cases. Screens potential case management clients, following identification for appropriateness/benefit of case management services. Interviews and provides individual counseling, as needed. Addresses services needed to optimize current health, psychosocial, spiritual status, and benefits of case management services. As required, enters approved metrics, patient data, and clinical progress notes into a prescribed database. Conducts comprehensive assessment of patients, to establish in detail and specificity, the nature of their care needs, as well as causal and contributing conditions and circumstances. Conducts comprehensive clinical interviews with the patient and other family members, as warranted, and collects pertinent data from all involved health care agencies, medical providers and resource programs. Participates in a multi-disciplinary team to develop a treatment plan to address all identified conditions and problems. Identifies psychosocial aspects of anticipated care needs, to identify potential barriers to optimal health, resource utilization, and methods for minimizing such barriers. Assists the patient and the family in developing, documenting, and implementing appropriate care plans, and accessing agencies and care providers. Applies a holistic approach to address health care needs, in collaboration with all health team members, to include the patient and the patient's family, as warranted. Serves as an advocate for patients, and their families, in obtaining services and support. Serves as a senior nursing leader and advances the nursing profession in case management. Introduces innovative nursing techniques, practices, and approaches, in collaboration with health care providers, to identify, plan, assess, and coordinate care programs, designed to provide efficient, comprehensive, and cost effective service for case-managed patients, throughout the continuum of care. Conducts training in nurse case management for professional and paraprofessionals personnel, within the medical treatment facility (MTF). Provides education, counseling, and clinical assistance, in advanced techniques, to nursing personnel, medical students, interns/residents, staff physicians, and administrators. Provides formal and informal consultation, briefings, and educational offerings. Represents the case management service, on or before, a variety of committees, boards, agencies, and concerned groups, as directed. Coordinates with a patient-focused multidisciplinary team of clinicians to develop time-line protocols and high quality, affordable health care for selected case-managed patients and beneficiaries, facilitating desirable patient outcomes. Identifies strategies to improve patient access, reduce administrative burdens for DOD beneficiaries, and improve the cost effectiveness for the civilian/military health care delivery system. Identify problems with health care access and utilization, in both the military and civilian sectors, and recommends alternatives to overcome difficulties. Interface with local, state, and federal agencies in obtaining regulations, policy manuals, and handouts, developing procedural guidelines to provide access to available programs. Ensure guidelines are in compliance with case management standards of practice. Proposes regulatory and administrative changes to resolve identified problems or concerns. Coordinates patient care through a continuum and facilitate the achievement of optimal outcomes in relation to care, quality and cost effectiveness. Maintains excellent patient assessment skills, use the nursing process as a basis for professional practice, and demonstrate proper preparation of patients for treatments and procedures, to include surgical interventions. Prescribes and communicates treatment plans in accordance with established acceptable practices in established MTF policy and procedures and IAW JC guidelines. Telephone and in-person assessment/evaluation includes the determination of optimal time and location for patient management (ER, clinic, homecare) and follow-up care as required. Collects and assesses significant patient history information and performs all necessary patient teaching. Demonstrates and adheres to peri-operative, infection control and safety policies and procedures used in the MTF and IAW JC guidelines. Schedules referral appointments, arranges for procedures, and performs telephone follow-up, as appropriate. Ensures compliance with standard of care and practice in accordance with all established policies, procedures, and guidelines used in the medical treatment MTF and IAW JC guidelines. Provides care within ethical and legal boundaries. Completes orientation and competency verification programs in accordance with unit guidelines. Serves and participates in committees, functions and other meetings, when assigned. Provides relevant and timely information and assist with decision-making and process improvement. Reports to the Nurse Manager and take direction from the charge nurse and house supervisor as required in maintaining a safe environment for staff and patient(s). Participates in the orientation, training and evaluation of duty performance of newly assigned personnel, as appropriate, when required. Participates in customer service initiatives and medical readiness activities designed to enhance health services, as required. Documents as directed, the disposition of referrals, MEPERS, EOM reports, and actively participates in weekly/bi-weekly medical management conferences and report any updates to the staff on practice guidelines. Follow a systematic process to identify patients in need of referrals. Reports high risk, high cost, and difficult patient situations, to the Department Head as indicated. Provides orientation for other new to the role and/or the facility. Maintain education specific to the department and certification requirements as necessary. Documents as directed, the Case Management (CM) workload and patient care plans, MEPRS, EOM reports, and actively participate in weekly case management patient care conferences. Follows a systematic process to identify patients for referral to Case Management. Report high risk, high cost, and difficult situations, to the Department Head as indicated. Provides orientation for Case Managers new to the role and/or the facility. Maintain education specific to the department and certification requirements as necessary. Serves as advisor and consultant regarding development, implementation, and management of the MTF healthcare UM/RM activities. Utilizes critical thinking skills to support, coordinate, and implement all aspects and stages of the UM/RM program, identifying patient care process improvements, through continual review of processes. Utilizes critical thinking skills to support, coordinate, and implement all aspects and stages of the UM/RM program, identifying patient care process improvements, through continual review of processes. Entails coordination of clinical care and services for active-duty services members, family members, and retirees covered by the Tricare Prime insurance benefit. Case Management recipients may have experienced a catastrophic injury or have been newly diagnosed with a chronic illness requiring the extensive use of resources and who need help navigating the system to facilitate appropriate delivery of care and services. Performance primarily in cubicle in Building 17B, but position will also require an office in Behavioral Health in Building 19. Is responsible for tracking and monitoring active-duty cases admitted for behavioral health issues, alcohol and drug related issues, as well as traumatic brain injuries. #INDKF

Requirements

Degree or diploma for a professional nursing program approved by the legally designated State accrediting agency.
Active current registration as a professional nurse in a State, District of Columbia, or a territory of the United States.
Basic Life Support for Healthcare Providers, American Heart Association, or American Red Cross Healthcare Provider Course.
Legal Authorization to Work in the United States
Be a U.S. Citizen
Ability to read, write, speak and understand English well enough to effectively communicate with all patients and other health care providers.
Knowledge of equipment and supply terminology and possess skills sufficient to identify and use necessary equipment and supplies properly and to communicate proper use with nurses, medical staff, patients, and family members.
Be sufficiently skilled to teach patients proper self-care and to motivate patients and family members to continue the procedures for promoting rapid healing.
Shall be knowledgeable and possess skills necessary to provide care appropriate to any age-related needs of the patients.
Knowledge of the principles of growth and development appropriate to the patient population served: Infants, Children, Adolescents, Adults, and Geriatrics (>65).
Knowledge of a wide range of medical disorders/conditions, diagnostic studies and treatments related to prevention, and detection of illnesses in adults, is desirable.
Knowledge in professional care theories, principles, practices, and procedures to perform nursing assignments of moderate difficulty and experience in assessing adult and geriatric patients, as appropriate.
Knowledge of computer operations and possess proficiency in the use of basic word processing, data entry and automated medical records.
Ability to function as a member of a multidisciplinary team in the coordination of patient care and outcomes.
Possess excellent oral communication skills for patient/family education, and excellent written communication skills to perform accurate documentation, both written and electronic, of all activity in accordance with requirements.
Knowledge of a variety of pharmacological agents used in patient treatment, the desired effects, side effects, and complications of their use as well as the accurate administration of the pharmacologic agent, including dosage calculations as required.
Knowledge of administrative requirements for the documentation of patient's condition, progress and acknowledgement of teaching, and follow up care.
Possess good time management skills.
Ability to facilitate continual patient-centered and outcome driven health performance improvement initiative by reviewing, processing and providing appropriate disposition of referrals that may involve coordination of clinical care and services for active duty services members, family members, and retirees covered by the Tricare Prime insurance benefit.
Essentris Armed Forces Health Longitudinal Technology Application (AHLTA) (MHS Genesis) formally known as the Armed Forces Health Longitudinal Technology Application (AHLTA).
Contractor HCP shall attend training in the use of MHS Genesis.
Defense Enrollment Eligibility Reporting System (DEERS)

Nice To Haves

Clinical subspecialty experience in Behavioral Health (2-5 years current experience).
Referral Management/Utilization Management (RM/UM) experience.

Responsibilities

Timely processing of Right of First Refusal (ROFR) requests, screening of specialty care referrals, sustaining up-to-date Specialty Clinic Booking Guidance, MTF Capabilities Report, ROFR Reports, maintaining up-to-date MTF/Managed Care Support Contract (MCSC) Memorandums of Understanding (MOUs), comply with Referral and Authorization Business rules, tracking, accounting, and resulting of referrals, and full use of RM information management systems.
Conduct reviews for medical necessity, preauthorization, medical appeals, collection and recovery from insurance carriers, and right of first refusal activities.
Maintenance of RN License requirements/certifications, availability for random drug tests, Physical, Security and any other WRNMMC Policy adherence.
Teach patients proper self-care and to motivate patients and family members to continue the procedures for promoting rapid healing.
Provide care appropriate to any age-related needs of the patients.
Function as a member of a multidisciplinary team in the coordination of patient care and outcomes.
Perform accurate documentation, both written and electronic, of all activity in accordance with requirements.
Facilitate continual patient-centered and outcome driven health performance improvement initiative by reviewing, processing and providing appropriate disposition of referrals that may involve coordination of clinical care and services for active duty services members, family members, and retirees covered by the Tricare Prime insurance benefit.
Provide professional case management services at Walter Reed National Military Medical Center (WRNMMC) or Fort Belvoir Community Hospital (FBCH).
Function as a member of a multidisciplinary team to meet individual and family comprehensive health needs.
Plan, coordinate, facilitate, and evaluate health care, serving as an advocate for patient options and services.
Utilize communication and available resources to promote quality and cost-effective outcomes, across the continuum of care.
Serve as a clinical case manager and patient advocate, providing advanced practice clinical, administrative, and organizational skills in managing the continuity, access, and provision of care services for complex and defined patients, to include catastrophic and end-of-life patient populations.
Be responsible for identification and management of patients with targeted, high risk and high cost diagnoses.
Independently perform difficult and complex assessment, review, coordination, planning, monitoring, evaluation and analysis of cases.
Screen potential case management clients, following identification for appropriateness/benefit of case management services.
Interview and provide individual counseling, as needed.
Address services needed to optimize current health, psychosocial, spiritual status, and benefits of case management services.
Enter approved metrics, patient data, and clinical progress notes into a prescribed database.
Conduct comprehensive assessment of patients, to establish in detail and specificity, the nature of their care needs, as well as causal and contributing conditions and circumstances.
Conduct comprehensive clinical interviews with the patient and other family members, as warranted, and collects pertinent data from all involved health care agencies, medical providers and resource programs.
Participate in a multi-disciplinary team to develop a treatment plan to address all identified conditions and problems.
Identify psychosocial aspects of anticipated care needs, to identify potential barriers to optimal health, resource utilization, and methods for minimizing such barriers.
Assist the patient and the family in developing, documenting, and implementing appropriate care plans, and accessing agencies and care providers.
Apply a holistic approach to address health care needs, in collaboration with all health team members, to include the patient and the patient's family, as warranted.
Serve as an advocate for patients, and their families, in obtaining services and support.
Serve as a senior nursing leader and advances the nursing profession in case management.
Introduce innovative nursing techniques, practices, and approaches, in collaboration with health care providers, to identify, plan, assess, and coordinate care programs, designed to provide efficient, comprehensive, and cost effective service for case-managed patients, throughout the continuum of care.
Conduct training in nurse case management for professional and paraprofessionals personnel, within the medical treatment facility (MTF).
Provide education, counseling, and clinical assistance, in advanced techniques, to nursing personnel, medical students, interns/residents, staff physicians, and administrators.
Provide formal and informal consultation, briefings, and educational offerings.
Represent the case management service, on or before, a variety of committees, boards, agencies, and concerned groups, as directed.
Coordinate with a patient-focused multidisciplinary team of clinicians to develop time-line protocols and high quality, affordable health care for selected case-managed patients and beneficiaries, facilitating desirable patient outcomes.
Identify strategies to improve patient access, reduce administrative burdens for DOD beneficiaries, and improve the cost effectiveness for the civilian/military health care delivery system.
Identify problems with health care access and utilization, in both the military and civilian sectors, and recommends alternatives to overcome difficulties.
Interface with local, state, and federal agencies in obtaining regulations, policy manuals, and handouts, developing procedural guidelines to provide access to available programs.
Ensure guidelines are in compliance with case management standards of practice.
Propose regulatory and administrative changes to resolve identified problems or concerns.
Coordinate patient care through a continuum and facilitate the achievement of optimal outcomes in relation to care, quality and cost effectiveness.
Maintain excellent patient assessment skills, use the nursing process as a basis for professional practice, and demonstrate proper preparation of patients for treatments and procedures, to include surgical interventions.
Prescribe and communicate treatment plans in accordance with established acceptable practices in established MTF policy and procedures and IAW JC guidelines.
Telephone and in-person assessment/evaluation includes the determination of optimal time and location for patient management (ER, clinic, homecare) and follow-up care as required.
Collect and assess significant patient history information and performs all necessary patient teaching.
Demonstrate and adhere to peri-operative, infection control and safety policies and procedures used in the MTF and IAW JC guidelines.
Schedule referral appointments, arranges for procedures, and performs telephone follow-up, as appropriate.
Ensure compliance with standard of care and practice in accordance with all established policies, procedures, and guidelines used in the medical treatment MTF and IAW JC guidelines.
Provide care within ethical and legal boundaries.
Complete orientation and competency verification programs in accordance with unit guidelines.
Serve and participate in committees, functions and other meetings, when assigned.
Provide relevant and timely information and assist with decision-making and process improvement.
Report to the Nurse Manager and take direction from the charge nurse and house supervisor as required in maintaining a safe environment for staff and patient(s).
Participate in the orientation, training and evaluation of duty performance of newly assigned personnel, as appropriate, when required.
Participate in customer service initiatives and medical readiness activities designed to enhance health services, as required.
Document as directed, the disposition of referrals, MEPERS, EOM reports, and actively participates in weekly/bi-weekly medical management conferences and report any updates to the staff on practice guidelines.
Follow a systematic process to identify patients in need of referrals.
Report high risk, high cost, and difficult patient situations, to the Department Head as indicated.
Provide orientation for other new to the role and/or the facility.
Maintain education specific to the department and certification requirements as necessary.
Document as directed, the Case Management (CM) workload and patient care plans, MEPRS, EOM reports, and actively participate in weekly case management patient care conferences.
Follow a systematic process to identify patients for referral to Case Management.
Report high risk, high cost, and difficult situations, to the Department Head as indicated.
Provide orientation for Case Managers new to the role and/or the facility.
Maintain education specific to the department and certification requirements as necessary.
Serve as advisor and consultant regarding development, implementation, and management of the MTF healthcare UM/RM activities.
Utilize critical thinking skills to support, coordinate, and implement all aspects and stages of the UM/RM program, identifying patient care process improvements, through continual review of processes.
Entails coordination of clinical care and services for active-duty services members, family members, and retirees covered by the Tricare Prime insurance benefit.
Track and monitor active-duty cases admitted for behavioral health issues, alcohol and drug related issues, as well as traumatic brain injuries.