Utilization Review Nurse/Case Manager

SUMMARY: This position will actively and retrospectively review medical cases to confirm that patient receive appropriate care and ensures cost effectiveness of health care services. Utilization management relates to all components in the health care system including primary, specialty and inpatient settings.

• LOCATION: W Hill Blvd, Joint Base Charleston, SC 29404
• HOURS: 40 hours/week
• PAY: $37.52/hour

BENEFITS:

• 2 weeks’ vacation in the 1st 12 months plus…
• Major holidays off
• Medical, Vision, Dental, AD&D, & Life Insurances

REQUIREMENTS:

• Baccalaureate of Science in Nursing from the ACEN, NLNAC, or CCNE
• Nurse applicants must be a current U.S. licensed Registered Nurse.
• 6 years of clinical nursing experience within the last 36 months
• 1 year of previous experience in Utilization Management

MANDATORY KNOWLEDGE AND SKILLS:

• 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.
• Possesses 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.

UNIQUE MILITARY HEALTH CARE SYSTEMS/PROCEDURES: The Composite Health Care System (CHCS), MHS GENESIS, Armed Forces Health Longitudinal Technology Application (AHLTA), and ICD-B programs must be utilized for referral management services. Access will be granted by local MTF connectivity and the contractor shall comply with MHS communications and Government IT security standards and policies. The military facility will provide system accounts for MSS personnel after required training and security procedures have been completed by the contractor. If the Military Health Service processes moves away from specified systems, the government will modify the task order accordingly.

PERFORMANCE OUTCOMES:

• 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 MTF officials to ensure Health Service Inspection standards are met at the operational level.
• Assists in the development and implementation of 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 MTF management 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.
• Participates in in-services and continuing education programs. Briefs applicable data/slides to provider staff, executive staff, newcomers, as appropriate.
• 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 oversight and 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.

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.

Job Type: Full-time

Salary: Up to $37.52 per hour

Work Location: In person

Job Type: Full-time

Pay: $37.52 per hour

Expected hours: 40 per week

Benefits:

• Dental insurance
• Disability insurance
• Free parking
• Health insurance
• Life insurance
• Paid time off
• Referral program
• Vision insurance

Healthcare setting:

• Hospital

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday
• No nights
• No weekends

Experience:

• Clinical Nursing: 6 years (Required)
• Utilization review: 1 year (Required)

License/Certification:

• RN License (Required)

Ability to Relocate:

• Charleston, SC: Relocate before starting work (Required)

Work Location: In person