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Registered Nurse (RN) - Utilization Management (RMC) job in San Antonio, Texas.
The 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.
Our employees are our best assets! Come join our team of healthcare professionals where you are valued.
- Holidays off
- Fantastic PTO accrual rate
- Competitive Compensation
- Benefit Package (health, dental, and vision plans)
- Develops and implements a comprehensive Utilization Management plan/program in accordance with the facility's goals and strategic objectives.
- Performs data/metrics collection on identified program areas; analyzes and trends results, including over- and underutilization 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.
- 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 guidance and standards. Refers all first-level review failures for further review and disposition.
- Verifies eligibility of beneficiaries. Obtains pertinent information from patients/callers and updates data.
- 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 specific processes.
- Routinely monitors referral management CHCS queue to ensure patients referrals are appointed and closed out.
- Keeps abreast of MTF and local market services and capabilities. Updates capability report as needed/directed.
- Conducts referral reconciliation report as directed, identifying all open referrals and provides notification to appropriate personnel for resolution.
- Monitors active duty, reserve/guard admissions to civilian hospitals and notifies Case Manager and Patient Administration Element as required.
- Serves as a liaison with headquarters, TRICARE regional offices, MTF staff and professional organizations concerning Utilization Management practices.
- Collaborates with staff/departments.
- Coordinates and participates in interdisciplinary team meetings, designated facility meetings, and Care Coordination meetings. Shares knowledge and experiences gained from own clinical practice and education relevant to nursing and utilization management.
- Participates in the orientation, education and training of other staff. May serve on committees, work groups, and task forces at the facility. Provides relevant and timely information to these groups, and assists with decision-making and process improvement. Participates in customer service initiatives, performance and quality improvement measures and medical readiness activities designed to enhance health services.
- Must maintain a level of productivity and quality consistent with: complexity of the assignment; facility policies and guidelines; established principles, ethics and standards of practice of professional nursing; the Case Management Society of America (CMSA); American Accreditation Healthcare Commission/Utilization Review Accreditation Commission (URAC); Comprehensive Accreditation Manual for Hospitals (CAMH); Health Services Inspection (HSI); and other applicable DoD and Service specific guidance and policies. Must also comply with the Equal Employment Opportunity (EEO) Program, infection control and safety policies and procedures.
- Completes medical record documentation and coding, and designated tracking logs and data reporting as required by local instructions, policies and guidance.
- Completes all required electronic medical record training, MTF-specific orientation and training programs, and any mandated Utilization Management training.
- Basic Life Support (BLS)
- Bachelors of Science in Nursing (BSN)
- Graduate from a nursing program accredited by ACEN or CCNE.
- Three years of total nursing experience in a direct patient care clinical setting
- Utilization management, utilization review, or case management experience for 24 recent consecutive months.
- RN Licensure: Current, full, active, and unrestricted. Any U.S. state.
- Computer competency (Microsoft applications, Outlook, operations, and medical records)
Position contingent on contract award with a late Spring start date. Incumbents HIGHLY encourage to contact us! Come join our team of healthcare professionals!