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Registered Nurse - Utilization Management
Location:
North Charleston, SC
Description:
Summary: This position will actively and retrospectively review medical cases to confirm that patient receive appropriate care and ensures cost effectiveness of health care services. Utilization management relates to all components in the health care system including primary, specialty and inpatient settings. Duties & Responsibilities: Assist with orientation and training of other Medical Management staff and assist in providing, assessing, and improving a wide variety of customer service relations. Assists MTF officials to ensure Health Service Inspection standards are met at the operationallevel. Assists in the development and implementation of a comprehensive Utilization Management plan/program for beneficiaries within MTF's goals and objectives. This plan is based on using the 12-step approach as described in the DoD Medical ManagementGuide. Reviews previous and present medical care practices as needed for patterns, trends, or incidents of under or over utilization of hospital resources incidental to medical care provided to beneficiaries. Plans and performs reviews IAW established indicators and guidelines to provide quality cost-effective care. Ensures identified patient needs are addressed promptly with appropriate decisions. Provides timely, descriptive feedback regarding utilization reviewissues. Performs data/metric collection. Analyzes data and prepares reports to describe resource utilization patterns. Briefs applicable data/slides to provider staff, executive staff, newcomers, as appropriate. Identifies areas requiring intensive management or areas forimprovement. Maintains reports on which cases have been denied or received reduced third party payments and reports provider profiles to the MTF management for corrective action. Serves as a liaison with higher headquarters, TRICARE Regional Office, MTF national accreditation organization, professional organizations, and community health care facilities concerning Utilization Management. Participates in in-services and continuing education programs. Briefs applicable data/slides to provider staff, executive staff, newcomers, as appropriate. Establishes and maintains good interpersonal relationships with co-workers, families, peers, and other health team members. Submits all concerns through Utilization Management Director; be able to identify, analyze and make recommendations to resolve problems and situations regarding referrals. Be productive and perform with minimal oversight and direction. Be able to independently identify, plan, and carry out projects with consideration for the goals and objectives of the TRICARE Utilization Management Element. Develops detailed procedures and guidelines to supplement established administrative regulations and program guidance. Recommendations are based upon analysis of work observations, review of procedures, and application of guidelines. Qualifications: Mandatory knowledge and skills. Knowledge, skills and computer literacy to interpret and apply medical care criteria, such asInterQual or Milliman Ambulatory Care Guidelines. Must possess experience in performing prospective, concurrent, and retrospective reviews to justify medical necessity for medical care to aid in collection and recovery from multiple insurance carriers. Review process includes Direct Care and Purchase Care System referrals, ward rounds for clinical data collection, contacting providers to inform them of dollars lost for missing documentation, and providing documentation for appeals resolution. Possesses working knowledge of Ambulatory Procedure Grouping (APGs), Diagnostic Related Grouping (DRGs), International Classification of Diseases-Version 9 (ICD), and Current Procedural Terminology-Version 4 (CPT-4) coding. Possess excellent oral and written communication skills, interpersonal skills, and have working knowledge of computers, specifically the Internet, Microsoft Word, Microsoft Access, Microsoft Excel, and Windows. Education. Baccalaureate of Science in Nursing Program from a program approved by the Accreditation Center for Education in Nursing (ACEN, formerly NLNAC) or the Commission on Collegiate Nurse Education (CCNE) License/certification. Current, active, full, and unrestricted License to practice Nursing inaccordance with State Board requirements. Nurse applicants must be a current U.S. licensed Registered Nurse. License cannot be under investigation nor have any adverse action pending from a Nursing State Board or national licensing/certification agency. Experience. Six years of clinical nursing experience is required. One year of previous experience in Utilization Management is required. Full time employment in a nursing field within the last 36 months is mandatory. Equivalent combinations of education and experience may be qualifying if approved by the requesting location and the Contracting Officer. If education or experience is used to meet the specialized requirements of this position, it must be directly related to referral/utilizationmanagement. Work Environment/Physical Requirements. The work can be sedentary. However, there may be some physical demands. Requirements include standing, sitting or bending. Individual will be required to walk throughout facility to pick up family practice clinic, medical records, and radiology mail drop offs/signed referrals.
Company:
Healthcare Resolution Services
Posted:
December 26 2023 on ApplicantPro
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More About this Listing: Registered Nurse - Utilization Management
Registered Nurse - Utilization Management is a Nurse & Healthcare Registered Nurse Job at Healthcare Resolution Services located in North Charleston SC. Find other listings like Registered Nurse - Utilization Management by searching Oodle for Nurse & Healthcare Registered Nurse Jobs.
Registered Nurse - Utilization Management is a Nurse & Healthcare Registered Nurse Job at Healthcare Resolution Services located in North Charleston SC. Find other listings like Registered Nurse - Utilization Management by searching Oodle for Nurse & Healthcare Registered Nurse Jobs.