Registered Nurse - Utilization Management w/BONUS - 5186

RN - Utilization Management needed at Mountain Home Air Force Base in Mountain Home, Idaho.

Duties

The duties include, but are not limited to the following; Follows medical privacy and confidentiality (i.e. Health Insurance Portability and Accountability Act [HIPAA]) guidelines, The Joint Commission (TJC), and Clinical Practice Guidelines (CPGs). Works with computer applications/software to include Microsoft Office 365 programs, MS Outlook (e-mail) and internet usage. Must have a working knowledge of Ambulatory Procedure Grouping (APGs), Diagnostic Related Grouping (DRGs), International Classification of Diseases- Current Version (ICD), and Current Procedural Terminology-Current Version (CPT) coding; and McKesson (InterQual) and/or Milliman Care Guidelines. Performs prospective, concurrent, and retrospective reviews to justify medical necessity for requested medical care and to aid in collection and recovery from multiple insurance carriers. Collects clinical data from inpatient and outpatient sources; provides documentation for appeals or grievance resolution; applies critical thinking skills and expertise in resolving complicated healthcare, social, interpersonal and financial patient situations; applies problem-solving techniques to articulate medical requirements to patients, families/care givers, medical and non-medical staff in a professional and courteous way. Develops and implements a comprehensive Utilization Management plan/program in accordance with the facility’s goals and strategic objectives. Performs data/metrics collection on identified program areas; analyzes and trends results, including over- and underutilization of healthcare resources. Identifies areas for improvement and cost containment. Reports utilization patterns and provides feedback in a timely manner. Analyzes medical referrals/appointments and general hospital procedures and regulations by monitoring specialty care referrals for appropriateness, covered benefits, and authorized surgery/medical procedures, laboratory, radiology, and pharmacy. Performs medical necessity review for planned inpatient and outpatient surgery; and performs concurrent review to include Length of Stay (LOS) using appropriate criteria. Reviews previous and present medical care practices for patterns; trends incidents of under-or over-utilization of resources incidental to providing medical care. Acts as referral approval authority for designated referrals per local/AF/DHA/DoD/national guidance and standards. Refers all first-level review failures to the SGH or other POC for further review and disposition. Verifies eligibility of beneficiaries using Defense Eligibility Enrollment Reporting System (DEERS). Obtains pertinent information from patients/callers and updates data in MHS GENESIS, local referral database, and other office automation software programs as appropriate and directed. Ensures and monitors specialty care referrals for appropriateness, medical necessity, and if the appointment, diagnostic testing, or procedure requested is a covered benefit according to appropriate health plan. If unsure, coordinates with TRICARE Regional Office Clinical Liaison Nurse or reviews TRICARE Operations Manual. Receives and makes patient telephone calls, written, or e-mail correspondence regarding specialty clinic appointments and referrals following facility-specific processes. Routinely monitors referral management queue to ensure patient referrals are appointed and closed-out. Keeps abreast of facility and local market services and capabilities. Updates capability report as needed/directed. Conducts referral reconciliation report as directed, identifying all open referrals and provides notification to appropriate personnel for resolution. Follows applicable local facility/AF/DHA/DoD instructions, policies, and guidelines. Completes medical record documentation and coding, and designated tracking logs and data reporting as required by local facility/AF/DHA/DoD instructions, policies, and guidance. Monitors active duty, reserve/guard admissions to civilian hospitals and notifies Case Manager and Patient Administration as required. Serves as a liaison with headquarters, TRICARE regional offices, facility staff and professional organizations concerning Utilization Management practices. Collaborates with staff/departments, including, but not limited to: Executive Management, Resource Management, Medical Records, Patient Administration, Group Practice Managers, Health Care Integrators, Coders/Coding Auditors, Population Health Nurse Consultants, Medical Management, Referral Management, TRICARE Operations, patient care teams, Quality Improvement, and the Managed Care Support Contractors. Coordinates and participates in interdisciplinary team meetings, designated facility meetings, and Care Coordination meetings. Shares knowledge and experiences gained from own clinical practice and education relevant to nursing and utilization management. Participates in the orientation, education and training of other staff. May serve on committees, work groups, and task forces at the facility. Provides relevant and timely information to these groups and assists with decision-making and process improvement. Participates in customer service initiatives, performance and quality improvement measures and medical readiness activities designed to enhance health services. Must maintain a level of productivity and quality consistent with: complexity of the assignment; facility policies and guidelines; established principles, ethics and standards of practice of professional nursing; the Case Management Society of America (CMSA); Comprehensive Accreditation Manual for Hospitals (CAMH); The Joint Commission (TJC); Unit Effectiveness Inspection (UEI); and other applicable Defense Health Agency (DHA), Department of Defense (DoD), and service-specific guidance and policies. Must also comply with the Equal Employment Opportunity (EEO) Program, infection control and safety policies and procedures. Completes all required electronic medical record training, facility-specific orientation and training programs, and any AF/DHA/DoD mandated Utilization Management training. Ensures a safe work environment, employee safe work habits and patient safety IAW regulatory agencies, infection control policies, and process improvement initiatives. Promote and contribute quality performance, performance improvement programs, and nursing practice in a setting that supports professional practice and sets a positive example; identify and deliver excellence in the delivery of nursing services and care to patients/residents; introduces and disseminates best practices in nursing services. Proactively identifies process issues that could lead to negative patient outcomes and participates in the appropriate safety reporting processes for the facility.