Registered Nurse (RN) - Utilization Management job in Great Falls, Montana.
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.
Fantastic PTO accrual rate
Benefit Package (health, dental, and vision plans)
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.
Graduate from a NLNAC or CCNE accredited college or university
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
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.
Position contingent on contract award. Incumbents HIGHLY encourage to contact us! Come join our team of healthcare professionals!
FSR provides healthcare professionals to government healthcare facilities supporting active military service members, retirees, and their families nationwide. Since 2004, FSR has matched talented individuals to organizations to create mutually beneficial, sustainable partnerships. FSR is a well-established, award winning organization built with committed professionals who have a unified vision of helping others to succeed and thrive. We invite you to join our team and grow with us! FSR is a woman-owned, minority, small business based out of Maryland.
Federal Staffing Resources dba FSR is an Equal Opportunity Employer: disability/veteran/military spouse This contractor and subcontractor shall abide by the requirements of 41 CFR 60-1.4(a), 60-300.5(a) and 60-741.5(a). These regulations prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, sexual orientation, gender identity or national origin. Moreover, these regulations require that covered prime contractors and subcontractors take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status or disability. 0 Associated topics: domiciliary, hospice, intensive care unit, maternal, nurse rn, psychiatric, registed, staff nurse, surgery, transitional
* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.