Utilization Management Registered Nurse

Katmai•Fort Carson, CO

31d•Onsite

About The Position

Provide a comprehensive utilization review (UR) and utilization management (UM) program for all TRICARE eligible beneficiaries within the CMHS.

Requirements

Associates Degree of Nursing.
Current, full, active, and unrestricted license to practice as a registered nurse.
Must be a graduate from a college or university accredited by Accreditation Commission for Education in Nursing (ACEN), the Commission on Collegiate Nursing Education (CCNE).
Basic Life support certification (BLS) course completed by the American Heart Association or American Red Cross.
Three (3) years within the last four (4) years as a registered nurse in utilization management.
One (1) year of experience in UR/UM and three (3) years of clinical nursing experience.
Must be able to read, understand, speak, and write English well enough to communicate effectively.
Proficient in the current versions of office automation software relevant to the role.
Must obtain and maintain any necessary security access and/or background checks.

Nice To Haves

Demonstrate a wide theory base and sound clinical skills to function as a nursing generalist.
Demonstrate customer-focused interpersonal skills in order to interact in an effective manner with physicians, health team members, community agencies, MTF's Referral Management Centers, as well as clients and families with diverse opinions, values, and religious and cultural ideals.
Knowledge of, and experience with Government regulations, procedures, limitations, and requirements within the scope of their area highly desired.
Working knowledge of EHR Genesis desirable.
Knowledge of Medical Terminology.

Responsibilities

Act as coordinator/liaison with providers, staff and Managed Care Support Contractor (MCSC) to ensure that actual health care received is appropriate to meet TRICARE beneficiaries' healthcare needs.
Gather information, identify, and analyze data, and develop recommendations to resolve problems related to the appropriate utilization of patient care services at the appropriate level of care.
Apply qualitative and quantitative analytical techniques, such as prospective, concurrent, and retrospective reviews. Determine the effectiveness of healthcare provided and refine methods, techniques, and processes as needed.
Use judgment to interpret or adapt available guidelines to individual situations and issues, and develop local guidelines and policies as needed.
Demonstrate full understanding of patient care standards, criteria, and guidelines to develop or adapt referral management processes, identify inefficiencies, recommend improvements to clinical practices, and institutionalize referral management concepts.
Establish and maintain referral management practices to monitor and evaluate health care quality and cost for Active Duty Army and Air Force personnel within CMHS.
Provide system-wide impact on clinical practices and resource use across the 4 MTFs, with analysis results informing MTF Commanders, TRICARE Regional Office, DHA, MEDCOM/AFMED, and DoD Service Components.
Identify beneficiaries with complex healthcare needs who may benefit from alternative treatment modalities, mechanisms, and/or lower levels of care. Identify areas of patient care services for process improvement to maximize utilization capabilities.
Ensure that the healthcare service is within the scope of practice and the TRICARE Operations Manual (TOM) access to care standards for appropriate utilization of services. Perform utilization management/review for medical necessity for specialty referrals and appropriate level of care.
Review and initiate recommendations to improve utilization activities throughout the continuum of care.
Provide the communication link between the providers, staff, and civilian sectors regarding UR guidelines.
Determine if the services requested are medically appropriate, cost effective, and provided in the appropriate setting.
Serve as a resource to and assist primary care managers with interpretation of guidelines and criteria for patient care and other systems. Identify and describe trends using all appropriate resources/tools. Discuss any problems with the military MTF providers and civilian providers and perform necessary follow-up with said providers.
Analyze aspects of healthcare provisions within the catchment areas that affect the financial utilization of the Government by using professional nursing knowledge of a wide range of nursing concepts, the ability to function independently with little or no supervision and understand all principles and practices.
Interface with HNFS, local, state, and federal agencies responsible for financing alternatives in healthcare, such as Medicare, Medicaid, and TRICARE Managed Support Contractors for which beneficiaries may be eligible.
Perform Right of First Refusal (ROFR) coordination of specialty care referrals.
Review specialty care referrals for appropriateness, completeness and route the referral to the appropriate place of care.
Conduct regular training for staff healthcare providers to teach them important nuances related to writing appropriate referrals to ensure quality and cost-effective care provided.
Utilize criteria for the ongoing systematic monitoring and evaluation of patient care utilization to include tracking appropriate data. Identify, document, analyze, report, and recommend strategies for follow up in issues related to over/under utilization, high cost, high volume, quality and risk management.
Maintain regular and punctual attendance.
Perform other duties as assigned.