(Archived) Utilization Manager Registered Nurse

Utilization Manager Registered Nurse

Location: Colorado Military Health System, CO

Work Schedule: Works Monday through Friday. Shifts may be 8 to 10 hour per day, but will not go over 40 hours a week. Duties will need to be performed at the Colorado Military Health System (CMHS) building during core CMHS hours (0600-1700).

SUMMARY: Serves as an analyst of clinical care based upon referrals for patient care services, medical record information and interaction with providers and MTF staff. Utilizes criteria-based, systematic evaluation of the medical necessity, appropriateness, and efficiency of the use of healthcare services, procedures and facilities across the continuum of care.

DUTIES:
1.1. Provide a comprehensive UM/Case/Care Management program for all TRICARE eligible beneficiaries.
1.2. Acts as coordinator/liaison with providers, staff and Managed Care Support Contractor (MSCS) to ensure that actual health care received is appropriate to meet TRICARE beneficiaries healthcare needs.
1.3. Identifies beneficiaries with complex healthcare needs who may benefit from alternative treatment modalities, mechanisms, and/or lower levels of care. Identifies areas of patient care services for process improvement to maximize utilization capabilities.
1.4. Ensures 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. Performs utilization management/review for medical necessity for specialty referrals and appropriate level of care.
1.5. Reviews and initiates recommendations to improve utilization activities throughout the continuum of care. Provides the communication link between the providers, staff, and civilian sectors with regard to utilization review guidelines. Determines if the services requested are medically appropriate, cost effective, and provided in the appropriate setting.
1.6. Serves as a resource to and assists primary care managers with interpretation of guidelines and criteria for patient care and other systems. Identifies and describes trends using all appropriate resources/tools. Discusses any problems with the military medical treatment facility (MTF) providers and civilian providers and performs necessary follow-up with said providers.
1.7. Reviews requests for patient care services within the Colorado Springs Multi-Service Market area which includes Evans Army Community Hospital, the United Sates Air Force Academy, Peterson AFB, Schriever AFB, and civilian providers for conditions that require medical care. Optimizes the MHS by redirecting care into the MTF when appropriate and by optimizing utilization of those primary and specialty care services in a timely manner.
1.8. 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 understands all principles and practices.
1.9. Interfaces with HNFS, local, state, and federal agencies responsible for financing alternatives in healthcare, such as Medicare, Medicaid, and TRICARE Managed Support Contractor those beneficiaries may be entitled to.
1.10. Identifies problems with healthcare access and utilization in both the military and civilian sectors, and recommends alternatives. Problem areas may include enrollment, outpatient visits, procedures, emergency department visits, inpatient admissions, claims, appeals, grievances, and quality management issues.
1.11. Utilizes criteria for the ongoing systematic monitoring and evaluation of patient care utilization to include tracking appropriate data. Identifies, documents, analyzes, reports, and recommends strategies for follow up in issues related to over/under utilization, high cost, high volume, quality and risk management
1.12. Conducts regular training for staff healthcare providers to teach them important nuances related to writing appropriate referrals to ensure quality and cost-effective care provided.
1.13. Demonstrate a wide theory base and sound clinical skills to function as a nursing generalist.
1.14. Demonstrate customer-focused interpersonal skills in order to interact in an effective manner with physicians, health team members, community agencies, MTF’s Referral Management Centers, as well as clients and families with diverse opinions, values, and religious and cultural ideals.
1.15. Knowledge of, and experience with Government regulations, procedures, limitations and requirements within the scope of their area highly desired. Working knowledge of latest versions of office automation software utilized in their area of expertise required; working knowledge of Composite Health Computer System (CHCS) desirable.

Qualifications:

2.1. English Language Requirement. The contractor shall read, understand, speak, and write English fluently, and be a United States citizen.
2.2. Formal Education. Certification by a Utilization Management-specific program such as Certified Professional in Healthcare Management (CPHM) is desired.
2.3. License: Current licensure to practice nursing in Colorado. Must be licensed in the jurisdiction in which the MTF is located (i.e. Colorado). Must maintain an active license or authorizing document from the state in which they are practicing at no expense to the government. Copies of license shall be furnished to the Contracting Officer or designated representative prior to performance.
2.4. Certification: Basic Lifesaver Course (BLS) required.
2.5. Experience: One year of experience in UM and five years of clinical experience in nursing desired.

Akahi Associates Services

Akahi Services is a premier provider of healthcare workers to various military treatment facilities across the United States. With a corporate office in Honolulu, Hawaii and recruiting office in San Antonio, Texas we specialize in providing skilled, trained and highly successful healthcare workers, including RNs, CRNAs, Physicians, LPN/LVN, Licensed Social Workers, and many more.

We have a strong focus on providing our government customer with quality and superior service.

Akahi Services is an equal opportunity employer and Minorities, Females, Veterans, and Disabled persons are encouraged to apply. For further information, please click the link below to view the EEOIs The Law poster.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.

Only qualified individuals who are being considered will be contacted for an interview