Utilization Management Registered Nurse

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Job Title

Location

FORT CARSON, CO 80913 US (Primary)

Job Type

Full-time

Job Description

Provide a comprehensive utilization review (UR) and utilization management (UM) program for all TRICARE eligible beneficiaries within the CMHS.

• Act as coordinator/liaison with providers, staff and Managed Care Support Contractor (MCSC) to ensure that actual health care received is appropriate to meet TRICARE beneficiaries’ healthcare needs.
• Gather information, identify, and analyze data, and develop recommendations to resolve problems related to the appropriate utilization of patient care services at the appropriate level of care.
• Apply qualitative and quantitative analytical techniques, such as prospective, concurrent, and retrospective reviews. Determine the effectiveness of healthcare provided and refine methods, techniques, and processes as needed.
• Use judgment to interpret or adapt available guidelines to individual situations and issues, and develop local guidelines and policies as needed.
• Demonstrate full understanding of patient care standards, criteria, and guidelines to develop or adapt referral management processes, identify inefficiencies, recommend improvements to clinical practices, and institutionalize referral management concepts.
• Establish and maintain referral management practices to monitor and evaluate health care quality and cost for Active Duty Army and Air Force personnel within CMHS.
• Provide system-wide impact on clinical practices and resource use across the 4 MTFs, with analysis results informing MTF Commanders, TRICARE Regional Office, DHA, MEDCOM/AFMED, and DoD Service Components.
• Identify beneficiaries with complex healthcare needs who may benefit from alternate treatment modalities, mechanisms, and/or lower levels of care. Identify areas of patient care services for process improvement to maximize utilization capabilities.
• Ensure that the healthcare service is within the scope of practice and the TRICARE Operations Manual (TOM) access to care standards for appropriate utilization of services. Perform utilization management/review for medical necessity for specialty referrals and appropriate level of care.
• Review and initiate recommendations to improve utilization activities throughout the continuum of care.
• Provide the communication link between the providers, staff, and civilian sectors regarding UR guidelines.
• Determine if the services requested are medically appropriate, cost effective, and provided in the appropriate setting.
• Serve as a resource to and assist primary care managers with interpretation of guidelines and criteria for patient care and other systems. Identify and describe trends using all appropriate resources/tools. Discuss any problems with the military MTF providers and civilian providers and perform necessary follow-up with said providers.
• Analyze aspects of healthcare provisions within the catchment areas that affect the financial utilization of the Government by using professional nursing knowledge of a wide range of nursing concepts, the ability to function independently with little or no supervision and understand all principles and practices.
• Interface with HNFS, local, state, and federal agencies responsible for financing alternatives in healthcare, such as Medicare, Medicaid, and TRICARE Managed Support Contractors for which beneficiaries may be eligible.
• Perform Right of First Refusal (ROFR) coordination of specialty care referrals.
• Review specialty care referrals for appropriateness, completeness and route the referral to the appropriate place of care.
• Conduct regular training for staff healthcare providers to teach them important nuances related to writing appropriate referrals to ensure quality and cost-effective care provided.
• Utilize criteria for the ongoing systematic monitoring and evaluation of patient care utilization to include tracking appropriate data. Identify, document, analyze, report, and recommend strategies for follow up in issues related to over/under utilization, high cost, high volume, quality and risk management.
• Maintain regular and punctual…