- Utilize the Composite Health Care System (CHCS), AHLTA, Carepoint Healthcare Application Suite, Carepoint 3G and local MCSC computer programs for referral management services.
- Utilize and maintain standards in accordance with following publications:
- Air Force Medical Service (AFMS) Referral Management Center User's Guide.
- The Joint Commission (TJC) standards.
- Accreditation Association for Ambulatory Health Care (AAAHC) standards.
- TRICARE Operations Manuals.
- DoD TRICARE Management Activity Medical Management Guide.
- DoD TRICARE Management Activity Population Health Improvement Plan and Guide.
- Verify eligibility of beneficiaries using Defense Eligibility Enrollment Reporting System (DEERS). Obtain pertinent information from patients/callers and update data in CHCS, AHLTA, local referral database, and other office automation software programs as appropriate and directed.
- Ensure and monitor 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, coordinate with TRICARE Regional Office Clinical Liaison Nurse or reviews TRICARE Operations Manual.
- Receive and make patient telephone calls, written, or e-mail correspondence regarding specialty clinic appointments and referrals, following Military Treatment Facility (MTF)-specific processes.
- Review 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.
- Plan and perform reviews in accordance with established indicators and guidelines to provide quality, cost effective care. Ensure identified patient needs are addressed promptly with appropriate decisions. Provide timely, descriptive feedback regarding utilization review/management issues toappropriate staff.
- Perform data/metric collection. Analyze data and identify areas that require intensive management or areas for improvement.Prepare reports to describe resource utilization patterns and provide briefings to provider, executive, newcomer staff with appropriate and applicable data/slides.
- Ensure Medical Management staff provide, assess, and improve a wide variety of customer service
- Assist leadership and chain of command to ensure Health Service Inspection and Accreditation Association for
Ambulatory Health Care (AAAHC) standards are met at the operational level.
- Monitor active duty, reserve/guard admissions to civilian hospitals and notifies case manager and
Patient Administration Element daily if tasked to do so.
- Prepare and submit monthly reports as requested. Produce slides/briefings. Brief applicable data to
provider staff, executive staff, newcomers, or others as directed.
- Serve as a liaison with headquarters, TRICARE regional offices, MTF staff and professional
organizations concerning Utilization Management practices.
- Participate in in-services and continuing education programs. Serve as a member of the Prime Service Area
Executive Council (PSAEC) or ensures a nurse from Medical Management is present.
- Establish and maintain good interpersonal relationships with co-workers, families, peers, and other
health team members. Submit all concerns through Medical Management Director; be able to identify,
analyze, and make recommendations to resolve problems and situations regarding referrals.
- Be able to perform with minimal supervisory direction. Be able to independently identify, plan, and carry out
projects with consideration for the goals and objectives of the MTF's Utilization Management and Medical
- Develop 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.
- Proactively deliver preventive services to the enrolled population. Identify needs and coordinate provision for
staff training for timeliness of secondary/tertiary prevention needs. Ensure assigned teams know secondary/tertiary
preventive services. Operationally analyze provider specific population profile to assigned teams.
- Understand AFMS targeted clinical Healthcare Effectiveness Data and Information Set metrics.
- Other related duties as assigned to meet the requirements/needs of Medical Management.
- Knowledge, skills and ability to interpret and apply medical care criteria or guidelines, such as McKesson InterQual, Milliman Care Guidelines, and Clinical Practice Guidelines (CPGs).
- Possess experience in 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. Review process includes Direct Care and Purchased Care System referrals, and providing documentation for appeals orgrievance resolution.
- A working knowledge of Ambulatory Procedure Grouping (APGs), Diagnostic Related Grouping (DRGs), International Classification of Diseases-Current Version (ICD), and Current Procedural Terminology-Current Version (CPT) coding.
- Possess excellent oral and written communication and interpersonal skills.
- 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; Composite Health Care System (CHCS), Armed Forces Health Longitudinal Technological Application (AHLTA). Must possess knowledge, skills and computer program literacy to collect and analyze data.
- Knowledge and experience in Patient Advocacy, Patient Privacy, and Customer Relations.
- The work can be sedentary. However, there are some physical demands. Requirements include standing, sitting and bending. Individual will be required to walk throughout facility to pick up/drop off of medical records/referrals and/or discuss any referral concerns with the unit staff.
License - Certifications
- Baccalaureate of Science in Nursing degree from an approved National League of Nursing accredited educational institution.
- Current, active, full, and unrestricted license to practice Nursing in accordance with local U.S. State Board requirements. License cannot be under investigation nor have any adverse action pending from a Nursing State Board or national licensing/certification agency.
- Six years of broad-based clinical nursing experience is required. Three years of progressively increasing managed care responsibilities with a focus in Utilization Management (UM) or Managed Care is required. Full time employment in a nursing field within the last 12 months is mandatory.
- Equivalent combinations of education and experience may be qualifying if approved by the requesting location. If education or experience is used to meet the specialized requirements of this position, it must be directly related to managed care/ utilization management.
- Certification by a UM-specific program (most desirable) or a professional organization recognized by an accredited body for UM, such as: American Nurses Association (ANA), American Nurses Credentialing Center (ANCC), National Association of Healthcare Quality (NAHQ) or Certified Professional in Healthcare Quality (CPHQ). If the nurse does not have certification, it shall be achieved within 24 months of employment from one of the above entities.
- Current/maintained Basic Life Support certification.
US Citizenship Required:Yes
Current Clearance Level Required:None
Equal Opportunity Employer/Veterans/Disabled
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability. If you are an individual with a disability and require a reasonable accommodation to complete any part of the application process, or are limited in the ability or unable to access or use this on-lineapplication process and need an alternative method for applying, you may contact (210) 888-0775 orJobs@Avosys.comfor assistance.