Registered Nurse - Utilization Manager

Location: Eglin Hospital at Eglin AFB, Fort Walton Beach, FL.

Position Type- Onsite

EM Key Solutions is seeking a Registered Nurse (RN) for a full-time Utilization Review / Management position supporting the Medical Maintenance Team at Eglin Hospital, Eglin AFB, FL.

The work Schedule:

• Monday - Friday, 9 hours between 6:30 am and 5:30 pm, with a one-hour lunch
• No weekends or holidays

Job-Specific Position Duties:

The duties include, but are not limited to, the following:

• 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 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 the 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 the 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 the appropriate health plan. If unsure, coordinates with TRICARE Regional Office Clinical Liaison Nurse or reviews TRICARE Operations Manual.
• Receives and makes patient telephone calls and 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 and reserve/guard admissions to civilian hospitals and notifies Utilization 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. May serve as a member of the Prime Service Area Executive Council (PSAEC).
• Must maintain a level of productivity and quality consistent with the 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); CAMH; (AAAHC); 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, coding, and designated tracking logs and data reporting as required by local MTF/AF/DoD instructions, policies, and guidance.
• Knowledge of medical privacy and confidentiality (Health Insurance Portability and Accountability Act [HIPAA]), and accreditation standards of the Accreditation Association for Ambulatory Health Care (AAAHC), The Joint Commission (TJC), and Clinical Practice Guidelines (CPGs).
• Working knowledge of computer applications/software to include Microsoft Office programs, MS Outlook (e-mail), and internet familiarity, is required. The ability to input, extract, and format data from established databases is desired.
• Must possess excellent oral and written communication and interpersonal skills.
• Must 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. The review process includes Direct Care and Purchased Care System referrals, inpatient unit rounds for clinical data collection and providing documentation for appeals or grievance resolution.
• Must have 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; and McKesson (InterQual) and/or Milliman Care Guidelines.
• Must have 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.
• Must have knowledge and experience in Patient Advocacy, Privacy, and Customer Relations.
• Must demonstrate the ability to apply critical thinking skills and expertise in resolving complicated healthcare, social, interpersonal, and financial patient situations.
• Must possess organization, problem-solving, and communication skills to articulate medical requirements to patients, families/caregivers, medical and non-medical staff in a professional and courteous way.
• Familiarity with the Department of Defense (DoD), Federal, State, and non-profit healthcare systems and organizations, to include DoD Tri-Service Military Healthcare Systems, TRICARE purchased care system, Medicare, Medicaid, and the Veterans Administration (VA), is desired.

Required Qualifications:

• Education: Minimum ASN; BSN preferred
• Experience: Minimum 1-year previous Utilization Review/Management experience required; Employment in a nursing field within the last 12 months is mandatory; 6 years of active clinical nursing practice is desired.
• Licensure: Possess a current AHA or ARC BLS Healthcare Provider certification.

Clearance:

Applicants selected must possess the ability to pass a Government background check/security clearance.

About EM Key Solutions:

Founded in 2015, EM Key Solutions, Inc. (EMKS) is a Service-Disabled Veteran-Owned Small Business (SDVOSB) offering a broad range of services to support Federal Government enterprises in meeting their mission requirements and business demands. ​Relationships are key to EMKS! We adopt a customer-centric approach and proven management processes for every project we undertake. Through sound leadership and management principles, EMKS focuses on offering its clients the solutions they need to be successful throughout the project management lifecycle at the most competitive rates

If you are curious to learn more about EM Key Solutions, please visit our website at https://www.emkeysolutions.com/

EMKS is an Equal Opportunity/Affirmative Action Employer committed to hiring and retaining qualified and talented individuals. All qualified applicants will receive consideration for employment without regard to race, color, sex, sexual orientation, gender identity, religion, national origin, disability, veteran status, or other legally protected status.

Reasonable Accommodation Requests

EM Key Solutions is committed to working with and providing reasonable accommodation to individuals with physical and mental disabilities. If you need special assistance or accommodation while seeking employment, please e-mail human.resources@EMKEYSOLUTIONS.COM or call: (727)-292-1521 Human Resources. We will make a determination on your request for reasonable accommodation on a case-by-case basis.

E-Verify

As a Federal Contractor, we are required to use E-Verify to validate employees' ability to work legally in the United States.

EEO is the Law

The law requires EM Key Solutions to post a notice describing the Federal laws prohibiting job discrimination.

Pay Transparency Non-Discrimination

EM Key Solutions will not discharge or, in any other manner, discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay.

For information regarding your legal rights and protections, please click on the following link: https://www.emkeysolutions.com/labor-notices