Clinical Nurse - Utilization Management (class4276ds)
Medical | San Antonio, TX | Full Time, Contract, and Temporary
Clinical Nurse - Utilization Management
Work Location: Lackland AFB - San Antonio, Texas
JOB DUTIES IN ORDER OF IMPORTANCE: (These duties are illustrative only. Incumbents may perform some or all of these duties or other job- related duties as assigned.)
- 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 under utilization 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
- Graduate from an associate (AND) or baccalaureate degree (BSN) program in nursing accredited by national nursing accrediting agency recognized by the US Department of Education and State Board of Nursing
- License. Maintain an active, valid, current and unrestricted license (with no limitations, stipulation or pending adverse actions) to practice nursing as a registered nurse in any US state/jurisdiction.
- Must have a minimum of 3 years full-time experience in providing patient care, patient and staff education, administration, and/or research in Utilization Management.
- Obtain at least 20 continue education hours per year in healthcare or directly related to positions.
- Must maintain current Basic Cardiac Life Support verification IAW AFI 44-119.
- 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 computer applications/software to include Microsoft Office programs, MS Outlook (e-mail) and internet familiarity
- 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
- 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
- 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
- Working knowledge of the military health care system including TRICARE health benefits (is preferred)
InGenesis is dedicated to placing people in positions that preserve life, improve lives and inspire others. This does not happen without passionate people, skilled colleagues who are motivated to create innovative solutions and deliver superior service to our clients. Founded in 1998, InGenesis manages thousands of employees, including pioneering healthcare, science, technology and pharma professionals. The workforce solutions company includes almost half of the Fortune 500 in its nearly 300 clients. It is recognized as one of the largest healthcare staffing firms, and InGenesis is the largest minority/women owned healthcare staffing firm in North America.
We support a diverse workforce and is an Equal Opportunity Employer who does not discriminate against employees and applicants for employment on the basis of race, gender, color, religion, national origin, age, sexual orientation, gender identity, genetic information, disability, veteran status, or other classification protected by law.