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Licensed Practical Nurse for Referral Management
Location:
McConnell AFB
Description:
SUMMARY: This Licensed Practical Nurse will provide utilization management activities in the Referral Management Center. QUALIFICATIONS: Knowledge, skills and computer literacy to interpret and apply medical care criteria, such as InterQual or Milliman Ambulatory Care Guidelines. The Contractor must have a 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. Associate of Science in Nursing Program from an approved National League of Nursing. License/certification . Current, active, full, and unrestricted License to practice Nursing in accordance with State Board requirements. Nurse applicants must be a current U.S. licensed Practical Nurse. License cannot be under investigation nor have any adverse action pending from a Nursing State Board or national licensing/certification agency. Experience. 6 years of clinical nursing experience is required. Previous experience in Utilization Management is not 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/utilization management. 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 referral requests, medical records, and radiology results, or other completed paperwork. PERFORMANCE OUTCOMES: Reviews referrals for administrative, clinical completeness and appropriateness. Validates requested medical service, and authorizes surgery/medical procedures, laboratory, radiology, pharmacy, and general hospital procedures and regulations. Collaborates with TRICARE Regional Office Clinical Liaison Nurse and MTF Liaison to address any process issues or concerns. S chedules referral appointments in accordance with required Access to Care Standards within the direct care system or ou tside the MTF with network/non-network providers. Ensures appointing is done within the Access to Care standards for 90% of all referrals. Coor dinates with specialty referral clinics (internal or external) to obtain special patient instructions and/or tests required prior to appointment. Provides pre-appointment instructions to patients as well as the details regarding their referral appointment (i.e., date/time, provider, and location). Ensures patients receive necessary documentation appropriate for the referred medical care visit. Lo cates referral requests and ensures appropriate documents are available prior to all specialty appointments. Prints diagnostic reports and/or treatment profiles as necessary. Verifies eligibility of beneficiaries using Defense Eligibility Enrollment Reporting System (DEERS). Fac ilitates referral activities by participation in multidisciplinary team activities. Initiates/coordinate communication between beneficiaries, team members, internal staff and providers, network/outside providers and ancillary health care workers. Provides timely, descriptive feedback regarding utilization review issues. Re views and enters first right of refusal referrals into CHCS and database within one (1) business day of the date of the referral. In terfaces with the Managed Care Support Contractor (MCSC) and multidisciplinary personnel as need to ensure appropriateness of referrals. Submits referrals to non-network providers to TRICARE Service Center (TSC) for medical necessity/appropriateness review. P erforms data collection and review to identify areas requiring intensive management. Refers to case management officials if needed. Re ceives and makes patient telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. Routinely monitors referral management CHCS queue to ensure patients are being called that do not utilize the RMC walk-in service. C ontacts patients in event referral requests are invalid, disapproved by second level review/MCSC and reschedules patients as soon as possible or instructs patients of other health care options. Receives and appropriately forwards clinical phone consult requests from patients. Advises patients of what their referral/health treatment options are as related to their eligibility per beneficiary status and covered benefits. This includes eligibility for travel benefits. Coordinates with Aerovac units to make travel arrangements with the Global Patient Movement Requirements Center using the TRANSCOM Regulating and Command and Control Evacuation System as indicated. Ensures Aerovac personnel arrange travel orders and non-medical attendants as required for the patient and the patient is informed. Advises on Line-of-Duty issues. O btains pertinent information from patients/callers, referrals, physician or other officials. Enters data in CHCS, AHLTA, MHS GENESIS, Referral database, and other office automation software programs as appropriate. Tracks referral reports after appointments are kept. Ensures that results from other MTFs and from network/non-network providers are returned to the referring provider and to the medical record within required timelines and follow up with as necessary. Documents that paper referral results are properly filed in patient's health record. Job Posted by ApplicantPro
Company:
General Infomatics
Posted:
December 26 2023 on ApplicantPool
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More About this Listing: Licensed Practical Nurse for Referral Management
Licensed Practical Nurse for Referral Management is a Nurse & Healthcare Licensed Practical Nurse Job at General Infomatics located in United States. Find other listings like Licensed Practical Nurse for Referral Management by searching Oodle for Nurse & Healthcare Licensed Practical Nurse Jobs.
Licensed Practical Nurse for Referral Management is a Nurse & Healthcare Licensed Practical Nurse Job at General Infomatics located in United States. Find other listings like Licensed Practical Nurse for Referral Management by searching Oodle for Nurse & Healthcare Licensed Practical Nurse Jobs.