Utilization Management Nurse Carson

SUMMARY

Responsible for assuring the receipt of high quality, cost efficient medical outcomes for those enrollees identified as having the need for inpatient/outpatient precertification.

• Review precertification requests for medical necessity, referring to the Medical Director those that require additional expertise.
• Review clinical information for concurrent reviews.
• As part of the UMRN program, conduct ongoing availability, monitoring and oversight of non-clinical staff activities.
• Establish effective rapport with other employees, professional support service staff, customers, clients, patients, families, and physicians.
• Advocate quality care and enhanced quality of life.
• Prevent patient complications during hospital stay.
• Advocate decreased hospital stay when appropriate.
• Maintain accurate records of all patient related interactions.
• Maintain regular and punctual attendance.
• Perform other duties as assigned.

None.

• Bachelor of Science in Nursing (BSN) is required.
• Minimum of two (2) years of prior experience in Utilization Management.
• Must possess a current, active, full, and unrestricted Registered Nurses (RN) license in Colorado, be able to practice using a nurse compact state license or have a license from any United States jurisdiction (with no limitations, stipulations or pending adverse actions).
• Knowledge of medical privacy and confidentiality (Health Insurance Portability and Accountability Act [HIPAA]), and accreditation standards of AAAHC, The Joint Commission (TJC), and Clinical Practice Guidelines (CPGs).
• 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; CHCS, AHLTA).
• Must have a working knowledge of Ambulatory Procedure Grouping (APGs), Diagnostic Related Grouping (DRGs), International Classification of Diseases-Current Version (ICD), Current Procedural Terminology-Current Version (CPT) coding; and McKesson (Inter Qual) and/or Milliman Care Guidelines.
• Life Support
  
  Certifications:
  
  Must possess and maintain current Healthcare Provider Basic Life Support (BLS). This Certification must be current at all times, at no additional expense to the government.
• Must obtain and maintain the site's required health screening and immunization requirements.
• Must obtain and maintain all required documents, certifications, licenses, etc. listed on the credentialling checklist, sent by Katmai’s Credentialing Specialist, for this position for initial hire.
• Must obtain and maintain any necessary security access and/or background checks.

• Certification by a Utilization Management-specific program such as Certified Professional in Healthcare Management (CPHM) is desired.
• 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.
• Ability to effectively read, write and speak English in order to communicate with all patients and other healthcare providers.
• Ability to effectively communicate and collaborate with a diverse group of people for the purpose of informing the healthcare team of plans/actions, for teaching/education to benefit the patient/family and organization.
• Effectively uses appropriate communication format in addressing professional issues.
• Excellent written communication skills to perform accurate documentation, both written and electronic, of all activity in accordance with requirements.
• Must demonstrate ability to apply critical thinking skills and expertise in resolving complicated healthcare, social, interpersonal, and financial patient situations.

Full-time. May be required to work additional hours as needed to complete assignment or project.

All Market contractors are subject to working at a duty location at any of the Military Treatment Facilities (MTFs) or associated sub clinics within the Colorado Military Health System (CMHS).

None.

Work is performed primarily indoors at a well-lit military treatment facility such as a clinic, outpatient facility or hospital. The environment is normally air conditioned, but conditions may change dependent upon circumstances. Work may need to be performed in a fast-paced environment requiring quick thinking and rapid judgements. Employee will be exposed to a wide variety of clients in differing functions, personalities, and abilities.

Exposure to blood borne pathogens and bodily fluids, latex, radiation or other contaminants and safety issues. May be exposed to infection or diseases from contact with patients.

Position consists of seeing up close and sitting for long periods of time, bending, stooping, crouching, and lifting up to 20 pounds. Frequently uses hands/fingers for manipulation of…