Registered Nurse

Location: Robins Air Force Base

Position: Registered Nurse - Utilization Manager

Apply: Qualified candidates should please send resume and salary/wage requirements by email to Global Consulting International: chuck.blattner@gci-usa.com

CLINICAL NURSE - UTILIZATION MANAGEMENT

 

SUMMARY: 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.

 

1.            QUALIFICATIONS

 

1.1         Mandatory knowledge and skills.

 

1.1.1    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).

 

1.1.2    Working knowledge of computer applications/software to include Microsoft Office programs, MS Outlook (e-mail), and internet familiarity is required. The ability to input, extract, and format data from established databases is desired.

 

1.1.3    Must possess excellent oral and written communication and interpersonal skills.

 

1.1.4    Must possess experience in 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. Review process includes Direct Care and     Purchased Care System referrals, inpatient unit rounds for clinical data collection, and      providing documentation for appeals or grievance resolution.

 

1.1.5    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.

 

1.1.6    Must have knowledge and experience, or demonstrate comprehension during training, with software and databases currently employed at the MTF (e.g. Microsoft Office, Access, Excel and PowerPoint; Composite Health Care System [CHCS], Armed Forces Health Longitudinal Technological Application [AHLTA]). Must possess knowledge, skills and computer program literacy to collect and analyze data.

 

1.1.7    Must have knowledge and experience in Patient Advocacy, Patient Privacy, and Customer Relations.

 

1.1.8    Must demonstrate ability to apply critical thinking skills and expertise in resolving      complicated healthcare, social, interpersonal and financial patient situations.

 

1.1.9    Must possess organization, problem-solving and communication skills to articulate medical requirements to patients, families/care givers, medical and non-medical staff in a professional and courteous way.

 

1.1.10 Familiarity with Department of Defense (DoD), Federal, State, non-profit healthcare systems and organizations, to include DoD Tri-Service Military Healthcare Systems,   TRICARE purchased care system, Medicare, Medicaid and the Veterans Administration (VA) is desired.

 

1.2         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.

 

1.3         Experience.  One year of previous experience in Utilization Management is required.  Employment in a nursing field within the last 12 months is mandatory.  6 years of active clinical nursing practice is desired.

 

1.4         Certification.  Certification by a UM-specific program such as Certified Professional in Healthcare Management (CPHM) is desired.

 

1.5          Work Environment/Physical Requirements. Requirements include prolonged walking, standing, sitting or bending, and computer use.  Position may require patient visitation at another medical treatment facility.  May have exposure to communicable illnesses.