(Archived) Registered Nurse (RN) - Utilization Management

Contract position with a Spring 2019 start date. Position contingent on contract award. Incumbents highly encourage to contact us. Come join our team of healthcare professionals!

Registered Nurse (RN) - Utilization Management job in Minot, North Dakota.

The Registered Nurse (RN) - Utilization Management job is within the military medical system and is a civilian position. Civilian and military personnel work together in the extensive military medical system. The hospitals and medical clinics provide services to the active duty military service members, military retirees, and their families and provide a full range of medical services.

Our employees are our best assets! Come join our team of healthcare professionals where you are valued.

• Monday-Friday
• Days
• Fantastic PTO accrual rate
• Competitive Compensation
• Benefit Package (health, dental, and vision plans)

Registered Nurse (RN) - Utilization Management Job Overview:

• Develops and implements a comprehensive Utilization Management plan/program in accordance with the facility's goals and objectives.
• Performs data/metrics collection on identified program areas; analyzes and trends results, including over- and under utilization of healthcare resources. Identifies areas for improvement and cost containment. Reports utilization patterns and provides feedback in a timely manner.
• Analyzes medical referrals/appointments and general hospital procedures and regulations by monitoring specialty care referrals for appropriateness, covered benefits, and authorized surgery/medical procedures, laboratory, radiology and pharmacy.
• Performs medical necessity review for planned inpatient and outpatient surgery; and performs concurrent review to include length of stay (LOS) for the facility's inpatients using appropriate criteria.
• Reviews previous and present medical care practices for patterns; trends incidents of under-or over-utilization of resources incidental to providing medical care.
• Acts as referral approval authority for designated referrals per local/AF/DoD/national guidance and standards. Refers all first-level review failures to the SGH or other POC for further review and disposition.
• Verifies eligibility of beneficiaries using Defense Eligibility Enrollment Reporting System (DEERS). Obtains pertinent information from patients/callers and updates data in CHCS, AHLTA, local referral database, and other office automation software programs as appropriate and directed.
• Ensures and monitors specialty care referrals for appropriateness, medical necessity, and if the appointment, diagnostic testing, or procedure requested is a covered benefit according to appropriate health plan. If unsure, coordinates with TRICARE Regional Office Clinical Liaison Nurse or reviews TRICARE Operations Manual.
• Receives and makes patient telephone calls, written, or e-mail correspondence regarding specialty clinic appointments and referrals following MTF-specific processes.
• Routinely monitors referral management Composite Health Care System (CHCS) queue to ensure patients referrals are appointed and closed out.
• Ensures Line of Duty paperwork is on file prior to authorization for all reserve and guard member referrals.

Registered Nurse (RN) - Utilization Management Job Qualifications:

• BLS
• ADN or BSN
• Graduate from a NLNAC or CCNE accredited college or university
• RN Licensure
• Minimum of 3 years for ADN or 2 years for BSN full-time experience in utilization management/utilization review or in broad-based clinical nursing
• Board Certification: Certified Professional in Healthcare Management (CPHM) by McKesson or a clinical specialty recognized by American Nurses Credentialing Center -OR- certification eligible with 3 years for ADN or 2 years for BSN experience

• Computer competency
• HIPAA, TJC, CPGs, AAAHC, APGs, DRGs, ICD, CPT coding; and McKesson (InterQual) and/or Milliman Care Guidelines.
• Experience in Patient Advocacy, Patient Privacy, and Customer Relations; performing prospective, concurrent, and retrospective reviews to justify medical necessity for requested medical care and to aid in collection and recovery from multiple insurance carriers; inpatient unit rounds for clinical data collection; providing documentation for appeals or grievance resolution; applying critical thinking skills and expertise in resolving complicated healthcare, social, interpersonal and financial patient situations.