Clinical Nurse – Utilization Management, Robins AFB, GA (41132) Job in Macon 31098, Georgia US
Clinical Nurse – Utilization Management, Robins AFB, GA (41132)
Serco Inc. is a leading provider of professional, technology and management services focused on the federal government. We advise, design, integrate and deliver solutions that transform how clients achieve their missions. Our customer-first approach, robust portfolio of services and global experience enable us to respond with solutions that achieve outcomes with value. Headquartered in Reston, VA, Serco Inc. has approximately 9,000 employees with annual revenue of $1.5 billion and is part of a $6.6 billion global business that helps transform government and public services around the world.
Serco recognizes that our employees are our most valuable asset. Our successes directly relate to our employees. At Serco, we listen, respect and support our employees and through continuous training, development and information-sharing, we advance talent internally, enhancing career growth and progression which enables not only our employees to excel but enables our customers to excel as well.
Our employees personally can make a difference. It is not just a job at Serco; at Serco, we offer career opportunities. We invite you to become part of our dynamic team.
Our Logistics team needs passionate people who care about the services they deliver to our customer; the United States Air Force. People who want to make a difference. We have an opportunity for a Clinical Nurse – Utilization Management at Robins AFB, GA.
Provides Utilization Management activities and functions by using MTF-specific Quality Improvement processes to identify areas for review from data, suspected problem areas, and input from departments/services within the facility. Prioritizes accordingly based on high dollar, high volume or problem prone diagnoses. Identifies gaps between desired and actual program outcomes and develops an action plan to fix gaps. Determines effectiveness of the plan and continually evaluates the impact of implementation. Incorporates applicable utilization review tasks to ensure patients receive the right care, at the right time, in the right place, with the right provider, at the right cost. Collaborates with staff, facility departments, and outside agencies to determine the best, most cost-efficient care.
Specific Responsibilities include but are not limited to:
- 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.
Serco is an equal opportunity/affirmative action employer committed to diversifying its workforce (M/F/D/V)
Required Skills:
Required Skills include but are not limited to:
- 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.
Required Experience:
Required Experiences include but are not limited to:
- Education. Shall be a graduate from an associate (ADN) or baccalaureate degree (BSN) program in nursing accredited by a national nursing accrediting agency recognized by the US Department of Education.
- License. Maintain an active, valid, current, and unrestricted license (with no limitations, stipulations or pending adverse actions) to practice nursing as a registered nurse in any US state/jurisdiction.
- 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.
- Certification. 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.
Criminal History Background Check (CHBC) and pre-employment drug screen are required.
Serco recognizes that it takes a diverse workforce with unique talents and perspectives to solve the challenging problems of our clients. We invite you to become a part of our dynamic team.
