Registered Nurse (RN) - Utilization Management 20-431

    Luke & Associates
    Valdosta, GA 31605
    Full-time, Part-time
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    Job Description

    Job Description

    This is a position listing for a Registered Nurse (RN) - Utilization Management position at the Moody AFB, Valdosta, GA. 

    All Luke & Associates positions have the sole purpose of providing quality medical attention to veterans, the military, and their families. Our commitment is to our employees, our clients and of course the patients and their safety.

    REGISTERED NURSE – UTILIZATION MANAGER

    SITE OF SERVICE: 

    • 23d Medical Group/Medical Management, Moody AFB.
    • HCWs shall receive notification two weeks prior to the reassignment to another location with a 40-mile commuting radius of their assigned MTF.

    POSITION QUALIFICATION/REQUIREMENTS:

    • Degree: Associates or Bachelors of Science in Nursing.
    • Education: Graduate from a college or university accredited by National League for Nursing Accrediting Commission (NLNAC), or The Commission on Collegiate Nursing Education (CCNE).
    • Experience: Must have at least 36 months of total nursing experience in a direct patient care clinical setting. Must have utilization management, utilization review or case management experience for 24 recent consecutive months 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) 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 . Must have experience in Patient Advocacy, Patient Privacy, and Customer Relations. Must be able to perform prospective, concurrent, and retrospective reviews to justify medical necessity for requested medical care and to aid in collection and recovery from multiple insurance carriers Must be able to collect clinical data from inpatient and outpatient sources; provide documentation for appeals or grievance resolution; apply critical thinking skills and expertise in resolving complicated healthcare, social, interpersonal and financial patient situations; apply problem-solving techniques to articulate medical requirements to patients, families/care givers, medical and non-medical staff in a professional and courteous way
    • Licensure: Current, full, active, and unrestricted license to practice as a Registered Nurse as required.
    • Certification: The HCW must be Certified/certification eligible in relevant specialty, such as Certified Managed Care Nurse through the American Board of Managed Care Nurses or Certified Informatics Nursing, Ambulatory Care Nursing, Medical-Surgical Nursing or Nursing Case Management through the American Nurses Credentialing Center
    • U.S. Citizenship: HCWs performing under this contract shall be U.S. citizens.
    • Able to read, write, and speak English well enough to effectively communicate.
    • Shall be physically capable of standing and/or sitting for extended periods of time and physically capable of performing all services required.

    SPECIFIC DUTIES:

    • 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) 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. 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); American Accreditation Healthcare Commission/Utilization Review Accreditation Commission (URAC); Comprehensive Accreditation Manual for Hospitals (CAMH); 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.
    • 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.
    • Functions as the alternate Special Needs Coordinator (SNC): The SNC is responsible for appropriately screening active duty family members for medical, psychological and/or educational special needs, enrolling those family members in the Exceptional Family Member Program (EFMP), and documenting the special conditions to facilitate Overseas/Permanent Change of Station clearances/EFMP assignment process according to Air Force Instructions.
    • The SNC works with the Family Member Relocation Clearance Coordinator (FMRCC) as well as the Chief of Medical Staff (SGH). The SNC will also interface with the Exceptional Family Member Program – Family Support (EFMP-FS) to identify appropriate resources for families with special needs and to educate the beneficiary population.

    CORE DUTIES:

    • 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.
    • Ensure compliance with standards of care and practice in accordance with all established policies, procedures, and guidelines used in the MTF.
    • Perform physical exam and health histories.
    • Provide health promotions, counseling, and education.
    • Administer medications, wound care, and numerous other personalized interventions.
    • Direct and supervise care provide by other healthcare professionals.
    • Accountable for making patient care assignments based on the scope of practice and skill level of assigned personnel.
    • Recognize adverse signs and symptoms and quickly react in emergency situations.
    • Communicate and collaborate with a diverse group of people for the purpose of informing the healthcare team of plans/actions, for teaching/education to benefit the patient/family and organization.
    • Make referral appointments and arrange specialty care as appropriate.
    • Perform nursing services identified in the TO.
    • Conduct research in support of improved practice and patient outcomes.
    • Participate in all phases of the Case Management Program (CMP) and ensure that the CMP meets established case management (CM) standards of care.
    • Provide nursing expertise about the CM process, including assessment, planning, implementation, coordination, and monitoring. Identify opportunities for CM and identify and integrate local CM processes.
    • Develop and implement local strategies using inpatient, outpatient, onsite and telephonic CM
    • Develop and implement tools to support case management, such as those used for patient identification and patient assessment, clinical practice guidelines, algorithms, CM software, and databases for community resources.
    • Integrate CM and utilization management (UM) and integrating nursing case management with social work case management.
    • Maintain liaison with appropriate community agencies and organizations.
    • Accurately collect and document patient care data.
    • Develop treatment plans including preventive, therapeutic, rehabilitative, psychosocial, and clinical interventions to ensure continuity of care toward the goal of optimal wellness.
    • Establish mechanisms to ensure proper implementation of patient treatment plan and follow-up post discharge in ambulatory and community health care settings.
    • Provide appropriate health care instruction to patient and/or caregivers based on identified learning needs.

    HOURS

    • Monday-Friday, Flexible hours, 0700-1800, not to exceed 40 hours per week.
    • Variations and lunch hour will be coordinated with the duty section.

    SPECIAL REQUIREMENTS/SKILLS:

    Must be comfortable in a fast-paced, dynamic environment.  Must be able and willing to reprioritize on short notice and work on multiple simultaneous projects.  Flexible and able to work with various personalities.  Team work skills required. Time management skills required. The ability to meet deadlines in a deadline intensive environment is essential. High level of adaptability and willingness to embrace change in a fast-paced, demanding environment.

    Luke & Associates does not discriminate on the basis of race, sex, color, religion, national origin, age, disability or veteran status in provision of services or employment opportunities and benefits. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, or national origin. 

     

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    Posting ID: 610261466Posted: 2021-03-21Job Title: Registered