Utilization Management Registered Nurse

Spectrum Healthcare Resources•Cheyenne, WY

1d•Onsite

About The Position

Spectrum Healthcare Resources has a potential opportunity for a civilian Utilization Management Registered Nurse at FE Warren Air Force Base in Cheyenne, WY. Full-time opportunity Monday through Friday, 40 hours per week Outpatient setting, providing care to our Active Duty Air Men and Women No on-call responsibilities Full complement of benefits to include health, dental and vision insurance, paid time off, 11 Paid Holidays, 401k and more Job Requirements: The Position will have the following requirements: Degree: Baccalaureate of Science in Nursing Program from an approved National League of Nursing. Education: Graduate from a college or university accredited by Accreditation Commission for Education in Nursing (ACEN), the Commission on Collegiate Nursing Education (CCNE). Experience: Six years of clinical nursing experience is required. One year of previous experience in Utilization Management is required. Full time employment in a nursing field within the last 36 months is mandatory. Knowledge, skills and computer literacy to interpret and apply medical care criteria, such as InterQual or Milliman Ambulatory Care Guidelines. 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. 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. The Contractor must have a 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.

Requirements

Degree: Baccalaureate of Science in Nursing Program from an approved National League of Nursing.
Education: Graduate from a college or university accredited by Accreditation Commission for Education in Nursing (ACEN), the Commission on Collegiate Nursing Education (CCNE).
Experience: Six years of clinical nursing experience is required.
One year of previous experience in Utilization Management is required.
Full time employment in a nursing field within the last 36 months is mandatory.
Knowledge, skills and computer literacy to interpret and apply medical care criteria, such as InterQual or Milliman Ambulatory Care Guidelines.
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.
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.
The Contractor must have a 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, unrestricted license to practice as a Registered Nurse in Wyoming

Responsibilities

Coordinate patient care in collaboration with a wide array of healthcare professionals.
Facilitate the achievement of optimal outcomes in relation to clinical care, quality and cost effectiveness.
Monitors specialty care referrals for appropriateness, covered benefit, and authorized surgery/medical procedures, laboratory, radiology, pharmacy, and general hospital procedures and regulations to analyze medical referrals/appointments. If unsure coordinates with TRICARE Regional Office Clinical Liaison Nurse and MTF Liaison to remedy errors or uncertainty.
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 Flight Commander to ensure Health Service Inspection standards are met at the operational level.
Receives and makes patient telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals.
Routinely monitors referral management Composite Health Care System (CHCS) queue to ensure patients are being called that do not utilize the Referral Management Center walk-in service.