What are the responsibilities and job description for the Clinical Nurse, Medical Management/Utilization Management position at CICONIX, LLC?
Clinical Nurse, Medical Management/Utilization Management
Upcoming program - help shape healthcare for the military!
The program supports the Healthcare Operations (HCO) Directorate, including TRICARE Health Plan (THP), Clinical Services, and related staff. It covers services for the management of THP programs, the Military Health System (MHS) health plan, TRICARE purchased health care services, human resources programs, and the operations of the HCO, THP Overseas Program, and the THP Front Office. The goal is to ensure the successful execution of the THP enterprise's missions and functions.
Responsibilities:
Provide expertise for all aspects of Utilization Management (UM) and Medical
Management (MM), Disease Management (DM) and Records Management (RM) for
performance of care delivered primarily for the MCSC and the six US Family Health Plan
(USFHP) designated providers. At a minimum provide the following subtasks:
- Conduct overarching planning to support operations and TRICARE policy implementation.
- Provide advisory input to the government in the areas of MM, DM, RM, and UM, specifically, the authorization process, focused reviews, concurrent and retrospective reviews, and appeals.
- Collaborate with the Managed Care Support Contractors and USFHP Clinical Quality Management Nurse Consultant to perform clinical assessment site visits for UM/MM.
- Provides advisory consultative services to the MCSCs and USFHP designated provider facilities regarding the contractor’s UM/MM program plan and activities.
- Serve as the primary point of contact and liaison to and between the MCSCs, Designated Providers and DHA regarding integration of UM/MM programs that would enhance the services and quality of care to TRICARE beneficiaries.
- Conduct research, review, and analysis on unforeseen, highly complex issues related to health benefits, cost containment, and the organization of program resources.
- Participate in and advise DHA/USFHP committees and/or working groups in the development of recommendations for regulations, guidelines, and procedures relating to program and business operations in addition to clinical operations for issues such as optimization of the USFHP facilities or innovative improvement programs.
Requirements:
- Bachelor's degree in Nursing. Masters preferred, or other clinically related Health Service degree.
- Department of Defense Program Management (PM) experience preferred, minimum 2 years within the last 5 years.
- Experience in the operations and organization of the Department of Defense Military Health System desired
Positions are contingent and will begin upon contract award.
About CICONIX: CICONIX LLC is a Veteran Owned Small Business specializing in business advisory and technical assistance for military health programs. We value exceptional people, unwavering integrity, inclusive collaboration, and enduring impact.
The Defense Health Agency (DHA) Healthcare Operations oversees the delivery of healthcare services to military personnel, their families, and eligible beneficiaries within the U.S. Department of Defense. This division focuses on improving operational efficiency, streamlining processes, and ensuring high-quality care across military treatment facilities, while supporting readiness and compliance with military health regulations.
CICONIX, LLC is an Equal Opportunity Employer, including disability/vets. We E-Verify all employees.
#LI-AD1