Registered Nurse Utilization Mgt-GTW Job in San Antonio 78201, Texas US
GTW, CONSULTANTS ASSOCIATES, LLC
Company Job Title: Registered Nurse Utilization Management
Chenega Job Title: Clinical Nurse-Utilization MGT
Clearance: Background
Location: TX, San Antonio
Reports To: Program Manager
FLSA Status: Regular, Full-Time, Salary, Non- Exempt
Prepared Date: 3/21/12
Approved Date: 3/21/12
Summary
This Registered Nurse (RN) will provide Utilization Management activities include timely processing of Right of First Refusal (ROFR); screening of specialty care referrals; sustaining up-to-date Specialty Clinic Booking Guidance; MTF Capabilities Report; ROFR Reports; maintaining up-to-date MTF/Managed Care Support Contract (MCSC) Memorandums of Understanding (MOUs); and comply with Referral and Authorization Business rules, tracking, accounting, and resulting of referrals. This RN will conduct reviews for medical necessity, pre-authorization, medical appeals, collection and recovery from insurance carriers, and right of refusal activities. The individual shall work with the executive staff of clinical operations, resource management, medical records, patient administration, and the quality division within the MTF to provide the appropriate level of resources and minimize cost for beneficiaries.
Essential Duties and Responsibilities Duties include, but are not limited to the following:
· Monitors specialty care referrals for appropriateness, covered benefit, and authorized surgery/medical procedures, laboratory, radiology, pharmacy, and general hospital procedures and regulations to analyze medical referrals/appointments. If unsure coordinates with TRICARE Regional Office Clinical Liaison Nurse and MTF Liaison to remedy errors or uncertainty.
· Assist with orientation and training of other Medical Management staff and assist in providing, assessing, and improving a wide variety of customer service relations. Assists Flight Commander to ensure Health Service Inspection standards are met at the operational level.
· Receives and makes patient telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. Routinely monitors referral management Composite Health Care System (CHCS) queue to ensure patients are being called that do not utilize the Referral Management Center walk-in service.
· Obtains pertinent information from patients/callers and enters data in CHCS, AHLTA, Referral database, and other office automation software programs as appropriate.
· Acts as an approval authority for all active duty and reserve/guard referrals under the supplemental health care program. Coordinates with SGH for all active, reserve and guard referrals not covered under the TRICARE benefit for approval. Ensures Line of Duty paperwork is on file prior to authorization. Verify eligibility of beneficiaries using Defense Eligibility Enrollment Reporting System (DEERS) and initiates/coordinate communication between beneficiaries, team members, internal staff and providers, network/outside providers and ancillary health care workers.
· Reviews and enters first right of refusal referrals into CHCS and database within one (1) business day of the date of the referral for proper processing in attempts to recapture workload from the network to the MTF. Keeps abreast of facilities services and medical treatment capabilities. Produces reports from databases and updates capability report as needed.
· Develops and implements a comprehensive Utilization Management plan/program for beneficiaries within MTF’s goals and objectives. This plan is based on using the 12-step approach as described in the DoD Medical Management Guide.
· Reviews previous and present medical care practices as needed for patterns, trends, or incidents of under or over utilization of hospital resources incidental to medical care provided to beneficiaries.
· Plans and performs reviews IAW established indicators and guidelines to provide quality cost-effective care. Ensures identified patient needs are addressed promptly with appropriate decisions. Provides timely, descriptive feedback regarding utilization review issues.
· Performs data/metric collection. Analyzes data and prepares reports to describe resource utilization patterns. Briefs applicable data/slides to provider staff, executive staff, newcomers, as appropriate. Identifies areas requiring intensive management or areas for improvement.
· Maintains reports on which cases have been denied or received reduced third party payments and reports provider profiles to the Medical Management Director/Chief Medical Services for corrective action.
· Serves as a liaison with higher headquarters, TRICARE Regional Office, MTF national accreditation organization, professional organizations, and community health care facilities concerning Utilization Management.
· Collaborates with Referral Management Center to ensure TRICARE Regional Office reconciliation report are run daily, identifies all open referrals and ensures resubmission. Ensures all referrals are reviewed and dispositioned in the appropriate manner (either electronically or manually). Monitors active duty, reserve/guard admissions to civilian hospitals and notifies case manager and Patient Administration Element daily. Prepares and submits monthly reports from encounter forms and ad hoc reports.
· Participates in in-services and continuing education programs. Serves as a member of the Prime Service Area Executive Council (PSAEC) or ensures a nurse representative is present. Briefs applicable data/slides to provider staff, executive staff, newcomers, as appropriate. Ensures self or nurse representative is available for all provider/nurse orientation briefings.
· Establishes and maintains good interpersonal relationships with co-workers, families, peers, and other health team members. Submits all concerns through Utilization Management Director; be able to identify, analyze, and make recommendations to resolve problems and situations regarding referrals.
· Be productive and perform with minimal supervisory direction. Be able to independently identify, plan, and carry out projects with consideration for the goals and objectives of the TRICARE Utilization Management Element. Develops detailed procedures and guidelines to supplement established administrative regulations and program guidance. Recommendations are based upon analysis of work observations, review of procedures, and application of guidelines.
Supervision
This position does not have supervisory responsibilities.
Minimum Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.
Education and/or Experience
· Education. Baccalaureate of Science in Nursing Program from an approved National League of Nursing.
· Six years of clinical nursing experience is required. One year of previous experience in Utilization Management is required. Full time employment in a nursing field within the last 36 months is mandatory.
· Equivalent combinations of education and experience may be qualifying if approved by the requesting location and the Contracting Officer. If education or experience is used to meet the specialized requirements of this position, it must be directly related to referral/utilization management.
· The work can be sedentary. However, there may be some physical demands. Requirements include standing, sitting or bending. Individual will be required to walk throughout facility to pick up family practice clinic, medical records, and radiology mail drop offs/signed referrals.
· Knowledge, skills and computer literacy to interpret and apply medical care criteria, such as InterQual or Milliman Ambulatory Care Guidelines.
· Must possess experience in performing prospective, concurrent, and retrospective reviews to justify medical necessity for medical care to aid in collection and recovery from multiple insurance carriers. Review process includes Direct Care and Purchase Care System referrals, ward rounds for clinical data collection, contacting providers to inform them of dollars lost for missing documentation, and providing documentation for appeals resolution.
· The Contractor must have a working knowledge of Ambulatory Procedure Grouping (APGs), Diagnostic Related Grouping (DRGs), International Classification of Diseases-Version 9 (ICD-9), and Current Procedural Terminology-Version 4 (CPT-4) coding.
· Possess excellent oral and written communication skills, interpersonal skills, and have working knowledge of computers, specifically the Internet, Microsoft Word, Microsoft Access, Microsoft Excel, and Windows.
Computer Skills
To perform this job successfully, an individual should have knowledge of Internet software; Excel Spreadsheet software and Word Processing software.
Certificates, Licenses, Registrations, Clearance:
· Current, active, full, and unrestricted License to practice Nursing in accordance with State Board requirements. Nurse applicants must be a current U.S. licensed Registered Nurse.
· License cannot be under investigation nor have any adverse action pending from a Nursing State Board or national licensing/certification agency.
Competencies - To perform the job successfully, an individual should demonstrate the following competencies:
Problem Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics.
Written Communication - Writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Presents numerical data effectively; Able to read and interpret written information.
Diversity - Demonstrates knowledge of EEO policy; Shows respect and sensitivity for cultural differences; Educates others on the value of diversity; Promotes a harassment-free environment; Builds a diverse workforce.
Ethics - Treats people with respect; Keeps commitments; Inspires the trust of others; Works with integrity and ethically; Upholds organizational values.
Strategic Thinking - Develops strategies to achieve organizational goals; Understands organization's strengths weaknesses; Analyzes market and competition; Identifies external threats and opportunities; Adapts strategy to changing conditions.
Planning/Organizing - Prioritize and plans work activities; Uses time efficiently; Plans for additional resources; Sets goals and objectives; Organizes or schedules other people and their tasks; Develops realistic action plans.
Professionalism - Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.
Innovation - Displays original thinking and creativity; Meets challenges with resourcefulness; Generates suggestions for improving work; Develops innovative approaches and ideas; Presents ideas and information in a manner that gets others' attention.
Qualifications - To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Language Skills - Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, proposals, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.
Mathematical Skills - Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
Reasoning Ability - Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to question activities and issues in all functional areas and make sound business decisions based on that data.
Physical Demands - The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this Job, the employee is regularly required to sit and talk or hear. The employee is frequently required to walk; use hands to finger, handle, or feel and reach with hands and arms. The employee is occasionally required to stand; climb or balance and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision.
Work Environment - The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.
The employee will normally work in a temperature-controlled office environment, with frequent exposure to electronic office equipment.
During visits to areas of operations, may be exposed to extreme cold or hot weather conditions. Is occasionally exposed to fumes or airborne particles, toxic or caustic chemicals, and loud noise.
Chenega Corporation is an EOE. AA/M/F/D/V. Native preference under PL 93-638. We participate in the E-Verify Employment Verification Program.
Minimum Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.
Education and/or Experience
• Education. Baccalaureate of Science in Nursing Program from an approved National League of Nursing.
• Six years of clinical nursing experience is required. One year of previous experience in Utilization Management is required. Full time employment in a nursing field within the last 36 months is mandatory.
• Equivalent combinations of education and experience may be qualifying if approved by the requesting location and the Contracting Officer. If education or experience is used to meet the specialized requirements of this position, it must be directly related to referral/utilization management.
• The work can be sedentary. However, there may be some physical demands. Requirements include standing, sitting or bending. Individual will be required to walk throughout facility to pick up family practice clinic, medical records, and radiology mail drop offs/signed referrals.
• Knowledge, skills and computer literacy to interpret and apply medical care criteria, such as InterQual or Milliman Ambulatory Care Guidelines.
• Must possess experience in performing prospective, concurrent, and retrospective reviews to justify medical necessity for medical care to aid in collection and recovery from multiple insurance carriers. Review process includes Direct Care and Purchase Care System referrals, ward rounds for clinical data collection, contacting providers to inform them of dollars lost for missing documentation, and providing documentation for appeals resolution.
• The Contractor must have a working knowledge of Ambulatory Procedure Grouping (APGs), Diagnostic Related Grouping (DRGs), International Classification of Diseases-Version 9 (ICD-9), and Current Procedural Terminology-Version 4 (CPT-4) coding.
• Possess excellent oral and written communication skills, interpersonal skills, and have working knowledge of computers, specifically the Internet, Microsoft Word, Microsoft Access, Microsoft Excel, and Windows.
Computer Skills
To perform this job successfully, an individual should have knowledge of Internet software; Excel Spreadsheet software and Word Processing software.
Certificates, Licenses, Registrations, Clearance:
• Current, active, full, and unrestricted License to practice Nursing in accordance with State Board requirements. Nurse applicants must be a current U.S. licensed Registered Nurse.
• License cannot be under investigation nor have any adverse action pending from a Nursing State Board or national licensing/certification agency.
