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Utilization Management Registered Nurse (RN) - Los Angeles AFB, CA

Los Angeles AFB, CA 90009

Posted: 07/13/2019 Industry: Nursing Job Number: 81332

Loyal Source Government Services is looking for a qualified Utilization Management Registered Nurse to work at Los Angeles  Air Force Base in California as a civilian contractor promoting and restoring patients’ health.

Our employees are our greatest asset! Benefits to working with Loyal Source include but are not limited to:
  1. Competitive wages
  2. Long-term contracts
  3. Any State License is acceptable

 

For more information, please contact Kaycee Turner at (321) 202-2762, or send a resume to k.turner@loyalsource.com.   

 

REQUIREMENTS:
  • Degree/Education: Bachelors of Science in Nursing. Graduate from a college or university accredited by National League for Nursing Accrediting Commission (NLNAC), or The Commission on Collegiate Nursing Education (CCNE).
  • Certifications in addition to Basic Life Support:
    • Certified/certification eligible in relevant specialty, such as Certified Managed Care Nurse through the American Board of Managed Care Nurses or Certified Informatics Nursing, Ambulatory Care Nursing, Medical-Surgical Nursing or Nursing Case Management through the American Nurses Credentialing Center
  • Experience: Must have at least 36 months of total nursing experience in a direct patient care clinical setting. Must have utilization management, utilization review or case management experience for 24 recent consecutive months
  • 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.
  • Must be skillful and tactful in communicating with people who may be physically or mentally ill, uncooperative, fearful, emotionally distraught, and occasionally dangerous.
  • Must be knowledgeable in and adhere to medical privacy and confidentiality (Health Insurance Portability and Accountability Act [HIPAA]); and The Joint Commission (TJC) standards.
  • Licensure/Registration: Current, full, active, and unrestricted license to practice as a Registered Nurse as required in the TO.

 

CORE RESPONSIBILITIES:
  • Develops and implements a comprehensive Utilization Management plan/program in accordance with the facility’ s goals and strategic objectives.
  • Performs 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. 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.
  • Keeps abreast of MTF and local market services and capabilities. Updates capability report as needed/directed.
  • Conducts referral reconciliation report as directed, identifying all open referrals and provides notification to appropriate personnel for resolution.
  • Monitors active duty, reserve/guard admissions to civilian hospitals and notifies Case Manager and Patient Administration Element as required.
  • Serves as a liaison with headquarters, TRICARE regional offices, MTF staff and professional organizations concerning Utilization Management practices.
  • Collaborates 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.
  • Coordinates and participates in interdisciplinary team meetings, designated facility meetings, and Care Coordination meetings. Shares knowledge and experiences gained from own clinical practice and education relevant to nursing and utilization management.
  • Participates in the orientation, education and training of other staff. May serve on committees, work groups, and task forces at the facility
  • Provides relevant and timely information to these groups, and assists with decision-making and process improvement. Participates in customer service initiatives, performance and quality improvement measures and medical readiness activities designed to enhance health services.
  • Must 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); Comprehensive Accreditation Manual for Hospitals (CAMH); 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.
  • Follows applicable local MTF/AF/DoD instructions, policies and guidelines.
  • Completes medical record documentation and coding, and designated tracking logs and data reporting as required by local MTF/AF/DoD instructions, policies and guidance.
  • Completes all required electronic medical record training, MTF-specific orientation and training programs, and any AF/DoD mandated Utilization Management training.
  • Ensures a safe work environment, employee safe work habits and patient safety IAW regulatory agencies, infection control policies, and process improvement initiatives. Promote and contribute quality performance, performance improvement programs, and nursing practice in a setting that supports professional practice and sets a positive example; identify and deliver excellence in the delivery of nursing services and care to patients/residents introduces and disseminates best practices in nursing services. Proactively identifies process issues that could lead to negative patient outcomes and participates in the appropriate safety reporting processes for the facility.
  • Prepares and submits monthly reports as requested. Produces slides/briefings.
  • Briefs applicable data to provider staff, executive staff, newcomers, or others as directed.
  • Participates in the orientation, education and training of other Medical Management and Referral Management Center staff.
  • Be able to perform with minimal direction. Be able to independently identify, plan and carry out projects with consideration for goals and objectives of the MTF’ s Utilization Management and Medical Management departments.

 

If you feel this opportunity is not right for you, please pass along this information and visit our website at www.loyalsource.com and follow us on LinkedIn, Facebook & Twitter for other current and future positions.

 

Loyal Source does not discriminate in employment on the basis of race, color, religion, sex (including pregnancy and gender identity), national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, membership in an employee organization, retaliation, parental status, military service, or other non-merit factor.

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