Registered Nurse (RN) - Utilization Management

Overview

ERP International is seeking full time Registered Nurse - Utilization Management (RN) in support of 56th Medical Group at Luke AFB, AZ. Apply online today and discover more about this exceptional employment opportunity. www.erpinternational.com

Be the Best! Join our team of exceptional health care professionals across the nation. Come discover the immense pride and job satisfaction ERP Employees experience in providing care for our Military Members, their Families and Retired Military Veterans! ERP International is honored to have been named one of The Washington Post's 2022 Top Workplaces!

* Excellent Compensation & Exceptional Comprehensive Benefits!
* Paid Vacation, Paid Sick Time, Plus 11 Paid Federal Holidays!

* Medical/Dental/Vision, STD/LTD/Life, and Health Savings Account available, and more!
* Annual CME Stipend and License/Certification Reimbursement!

* Matching 401K!

About ERP International, LLC: ERP is a nationally respected provider of health, science, and technology solutions supporting clients in the government and commercial sectors. We provide comprehensive enterprise information technology, strategic sourcing, and management solutions to DoD and federal civilian agencies in 40 states. Founded in 2006, ERP is headquartered in Laurel, MD and maintains satellite offices in Montgomery, AL and San Antonio, TX - plus project locations nationwide. ERP is an Equal Opportunity Employer - Disability and Veteran.

Responsibilities

Work Schedule:

Monday - Friday, 9 hours between 7:00am and 5:30pm, with a one hour lunch

Specific schedule is dependent upon the department

No Call, Weekends or Holidays

RN - UM Job Specific Qualifications and Knowledge:

• Must have knowledge of medical privacy and confidentiality (Health Insurance Portability and Accountability Act [HIPAA]), and accreditation standards of Accreditation Association for Ambulatory Health Care (AAAHC), The Joint Commission (TJC), and Clinical Practice Guidelines (CPGs); computer applications/software to include Microsoft Office programs, MS Outlook (e-mail), and internet familiarity; 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.
• Must have experience in Patient Advocacy, Patient Privacy, and Customer Relations; performing prospective, concurrent, and retrospective reviews to justify medical necessity for requested medical care and to aid in collection and recovery from multiple insurance carriers; inpatient unit rounds for clinical data collection; providing documentation for appeals or grievance resolution; applying critical thinking skills and expertise in resolving complicated healthcare, social, interpersonal and financial patient situations; applying problem-solving techniques to articulate medical requirements to patients, families/care givers, medical and non-medical staff in a professional and courteous way.

Core Duties: The duties include but are not limited to the following:

• Develops and implements a comprehensive Utilization Management plan/program in accordance with the facility's goals and 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) for the facility's inpatients 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/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 CHCS, AHLTA, 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 MTF-specific processes.
• Routinely monitors referral management Composite Health Care System (CHCS) queue to ensure patients referrals are appointed and closed out.
• Ensures Line of Duty paperwork is on file prior to authorization for all reserve and guard member referrals.
  Keeps abreast of MTF 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.
• Monitors active duty, reserve/guard admissions to civilian hospitals and notifies Case Manager and Patient Administration Element as required.
• Serves as a liaison with headquarters, TRICARE regional offices, MTF 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. May serve as a member of the Prime Service Area Executive Council (PSAEC).
• 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); American Accreditation Healthcare Commission/Utilization Review Accreditation Commission (URAC); CAMH; (AAAHC); Health Services Inspection (HSI); and other applicable DoD and Service specific guidance and policies. Must also comply with the Equal Employment Opportunity (EEO) Program, infection control and safety policies and procedures.
• Follows applicable local MTF/AF/DoD instructions, policies and guidelines.
• Completes medical record documentation and coding, and designated tracking logs and data reporting as required by local MTF/AF/DoD instructions, policies and guidance.
• Completes all required electronic medical record training, MTF-specific orientation and training programs, and any AF/DoD mandated Utilization Management training.

Qualifications

Minimum Qualifications:

* Education: Associates Degree of Nursing. Bachelor's Degree preferred.

* Experience:A minimum of 3 years for ADN or 2 years for BSN full-time experience in utilization management/utilization review or in broad-based clinical nursing.

* Licensure: Active/Unrestricted RN License from any state.

* Certifications: Certified Professional in Healthcare Management (CPHM) by McKesson or a clinical specialty recognized by American Nurses Credentialing Center -OR- certification eligible with 3 years for ADN or 2 years for BSN experience in utilization management/utilization review or in broad-based clinical nursing.

* Life Support Certifications: Possess and maintain an AHA or ARC Basic Life Support (BLS) certification.

* Security: Must possess ability to pass a Government background check/security clearance.