(Archived) Utilization Review Nurse

C2 ALASKA, LLC

Maxwell Ambulatory Healthcare Center, Maxwell AFB, AL

The Utilization Review Nurse shall develop and implement a comprehensive Utilization Management plan/program in accordance with the local facility’s goals and objectives.

• Perform 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.
• Report utilization patterns and provides feedback in a timely manner.
• Analyze 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.
• Perform 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.
• Review 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.
• Refer all first-level review failures to the SGH or other POC for further review and disposition.
• Verifie eligibility of beneficiaries using Defense Eligibility Enrollment Reporting System (DEERS).
• Obtain pertinent information from patients/callers and updates data in Genesis, local referral database, and other office automation software programs as appropriate and directed.
• Ensure 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.
• Receive and makes patient telephone calls, written, or e-mail correspondence regarding specialty clinic appointments and referrals following MTF-specific processes.
• Routinely monitors referral management Genesis queue to ensure patients referrals are appointed and closed out.
• Ensure Line of Duty paperwork is on file prior to authorization for all reserve and guard member referrals.
• Keep abreast of MTF and local market services and capabilities.
• Updates capability report as needed/directed.
• Conduct referral reconciliation report as directed, identifying all open referrals and provides notification to appropriate personnel for resolution.
• Monitor active duty, reserve/guard admissions to civilian hospitals and notifies Case Manager and Patient Administration Element as required.
• Serve as a liaison with headquarters, TRICARE regional offices, MTF staff and professional organizations concerning Utilization Management practices.
• Collaborate with staff/departments, including, but not limited to: Executive Management, Resource Management, Medical Records, Patient Administration, Group Practice Managers, Health Care Integrators, Coders/Coding Auditors, Population Health Nurse Consultants, Medical Management, Referral Management, TRICARE Operations, patient care teams, Quality Improvement, and the Managed Care Support Contractors
• Coordinate and participate in interdisciplinary team meetings, designated facility meetings, and Care Coordination meetings.
• Share knowledge and experiences gained from own clinical practice and education relevant to nursing and utilization management.
• Participate in the orientation, education and training of other staff. May serve on committees, work groups, and task forces at the facility.
• May serve as a member of the Prime Service Area Executive Council (PSAEC).
• 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); CAMH; (AAAHC); 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.
• Follow applicable local MTF/AF/DoD instructions, policies and guidelines.
• Complete medical record documentation and coding, and designated tracking logs and data reporting as required by local MTF/AF/DoD instructions, policies and guidance. Complete all required electronic medical record training, MTF-specific orientation and training programs, and any AF/DoD mandated Utilization Management training.
• All services provided shall be in accordance with applicable DoD, U.S. Air Force installation and facility directives, guidelines, programs and administrative requirements.
• Other duties as assigned

Qualifications

• Associate’s or Baccalaureate degree from a nationally accredited program in nursing recognized by the Education in Nursing (ACEN), the Commission of Collegiate Nursing Education (CCNE)
• Maintain an active, valid, current and unrestricted license (with no limitations, stipulations or pending adverse actions to practice nursing as a registered nurse in any US State.
• Shall have provided pediatrician services a minimum of twelve (12) months within the past two (2) years.
• Must also have at least three to five (3-5) years of experience in Pediatric Medicine to include residency/fellowship time.
• Pediatricians must meet all credentialing requirements for the MTF where they will be providing services.

Knowledge, Skills and Abilities

• Knowledge and ability to effectively apply the following core case management functions:

a) Assessment: Identification of patients for case management; comprehensive collection of patient information and medical status; and continued evaluation of an established plan of care;

b) Planning: Collaboration with the patient, family/caregiver, primary provider and other members of the health care team for developing an effective plan of care;

c) Facilitation: Care coordination and communication among all involved parties;

d) Advocacy: Support for the patient and family/caregivers to ensure identified education and appropriate, timely care is received

• Knowledge of a variety of pharmacological agents used in patient treatment, the desired effects, side effects, and complications of their use as well as the accurate administration of the pharmacologic agent, including dosage calculations as required.
• Knowledge of the military health care system including TRICARE health benefits or a working knowledge of the principles of fee-for-services, preferred provider network and managed care/HMO organizations is highly desirable.
• Knowledge of the administrative requirements for proper documentation of patient’s condition including disease progress, acknowledgement of teaching, and follow up care
• Knowledge of medical privacy and confidentiality (Health Insurance Portability and Accountability Act [HIPAA]), and accreditation standards of Accreditation Association for Ambulatory Health Care (AAAHC) and The Joint Commission (TJC), and the Clinical Practice Guidelines (CPGs)
• 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.
• Must demonstrate ability to communicate effectively both orally and in writing.
• Must be skillful and tactful in communicating with people who may be physically or mentally ill, uncooperative, fearful, emotionally distraught, and occasionally dangerous.
• 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; Medical Health System’s (MHS) Genesis.
• Must possess knowledge, skills and computer program literacy to collect and analyze data.
• Must have knowledge and experience in Patient Advocacy, Patient Privacy, and Customer Relations.
• Must demonstrate ability to apply critical thinking skills and expertise in resolving complicated healthcare, social, interpersonal and financial patient situations.
• Must possess organization, problem-solving and communication skills to articulate medical requirements to patients, families/care givers, medical and non-medical staff in a professional and courteous way.
• Familiarity with Department of Defense (DoD), Federal, State, non-profit healthcare systems and organizations, to include DoD Tri-Service Military Healthcare Systems, TRICARE purchased care system, Medicare, Medicaid and the Veterans Administration (VA) is desired.

Physical Demands (The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.)

• While performing the duties of this Job, the employee is regularly required to sit and talk or hear. The employee may use repeated motions that include the arms, wrists, hands and/or fingers. The employee is occasionally required to walk, stand, climb, balance, stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision.

Executive Order 13495, The Non Displacement of Qualified Workers Under Service Contracts provide first right of refusal to incumbents on contracts. If the position is accepted by the incumbent on the job, other application/resume of non-incumbents will not be reviewed.