Registered Nurse - Utilization Mangement

Overview

Avosys is a growing integrator of professional, technological and management solutions services. Founded in 1998, Avosys provides services nationwide to Federal, Commercial, Local and State clients. We recognize the foundation of our firm is our people and we continue to rise above our competition by hiring the best.

Is it your calling to serve our Nation’s Heroes? Avosys is seeking a Registered Nurse - Utilization Management to provide outpatient services to the military and their families at Malmstrom Air Force Base in Montana.

• Maximize family time with no weekend, Holiday, or on-call requirements
• Maintain work-life balance with guaranteed 8-hour shifts
• Take advantage of our competitive, comprehensive benefits package including medical, dental, vision, life, short-term disability, long-term disability & 401(k)

Responsibilities

• 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, MHS GENESIS, 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. 
•  

Qualifications

• 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), 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.
• Baccalaureate of Science in Nursing Program from an approved National League of Nursing.
• License/certification. 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.
• 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.
• Work Environment/Physical Requirements. 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.

License - Certifications

• Current, active, full, and unrestricted License to practice Nursing. 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.
• BLS Certification

Other Information

Industry: Defense

US Citizenship Required: Yes

Background Check: Required

Current Clearance Level Required: None

Telework: No

Travel: No

Equal Opportunity Employer/Veterans/Disabled

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability.  If you are an individual with a disability and require a reasonable accommodation to complete any part of the application process, or are limited in the ability or unable to access or use this on-line application process and need an alternative method for applying, you may contact (210) 888-0775 or Jobs@Avosys.com for assistance.