Nurse - Utilization Manager (2 positions)
Entourage Consulting (Placement /Human Resources) - San Diego, CA

This job posting is no longer available on Indeed. Find similar jobs: Nurse jobs - Entourage Consulting jobs

These roles are located on US Military Bases in Japan. Only qualified candidates who are able and willing to relocate to Japan will be considered

_Note_ Hiring decision will be made after 1st interview.

COMPANY DESCRIPTION
Entourage Consulting supports the US government. We provide comprehensive civilian staffing solutions to contract and procurement offices of US Government installations around the world. With our Headquarters in Sparks, NV and our APAC office in Tokyo, Japan we effectively help the U.S. government with contract staff augmentation and locum tenens services of civilian professionals. Entourage is a veteran owned, fully licensed, total service provider with more 40 years’ experience working with the US government and Department of Defense.

REQUIREMENTS AND QUALIFICATIONS

Education
Graduation from a State Board of Nursing approved training program or completion of equivalent United States military training that permits sitting for a state licensure examination.

License/certification
Nurse applicants must be a current U.S. LPN/LVN/RN. Active, current, valid and unrestricted license to practice nursing in accordance with State Board requirements. License cannot be under investigation nor have any adverse action pending from a Nursing State Board or national licensing/certification agency.

Experience
Four (4) years of clinical nursing experience is required. LPN/LVN shall have held full time employment in a nursing field for twelve (12) out of the last twenty-four (24) months (mandatory). Equivalent combinations of education and experience may be qualifying if the experience is directly related to utilization management.

Knowledge
Must have a working knowledge of Ambulatory Procedure Grouping (APGs), Diagnostic Related Grouping (DRGs), International Classification of Diseases-Version 9 (ICD-9), Current Procedural Terminology-Version 4 (CPT-4) coding and InterQual or Milliman Ambulatory Care Guidelines. Working knowledge is defined as having at least one (1) year of experience working these items or training certifications.

SPECIFIC TASKS

  • Works in collaboration with providers, case managers (CM), disease management (DM) nurses, health care integrator and group practice manager to determine measures to target and manage enrollees and/or processes that relate to high-cost, high-volume or problem-prone diagnoses, procedures, services and beneficiaries who have demonstrated high utilization rates. Uses the TRICARE Management Activity Medical Management Guide in performance of these duties. Makes appropriate recommendations to DMs and CMs for high-utilization or high-risk enrollees to be entered into their processes.
  • Conducts special analyses on patient utilization of health services and health care provider orders and referrals for specialty care, therapies, pharmaceuticals and diagnostic testing to identify both excessive and insufficient use of services (e.g., patients with 100% or more emergency room visits compared to the average of all patients; physicians who order 50% more special tests than their peers). Identifies ways to reduce overutilization and suboptimal underutilization of services.
  • Reviews referrals for administrative, clinical completeness and appropriateness in coordination with the Chief, Medical Staff (SGH) or deputy SGH. Completes medical necessity and benefit reviews on referrals and makes recommendations to the MTF approval authority for approval/disapproval of the specialty care requested. Coordinates with the TRICARE Overseas Program contractor as needed to determine availability of local care.
  • Schedules referral appointments in accordance with Air Force Access to Care (ATC) standards with DoD and civilian health care providers. Ensures appointing is done within the Access to Care standards. Notifies the MTF group practice manager, TRICARE Operations and Patient Administration Flight or SGH if ATC standards are not met for referrals.
  • Coordinates with specialty referral clinics to obtain special patient instructions and/or tests required prior to appointment. Provides pre-appointment instructions to patients as well as the details regarding their referral appointment (i.e., date/time, provider, and location). Ensures patients receive necessary documentation appropriate for the referred medical care visit.
  • Locates referral requests and ensures appropriate documents are available prior to all specialty appointments. Prints diagnostic reports and/or treatment profiles as necessary.
  • Verifies eligibility of beneficiaries using Defense Eligibility Enrollment Reporting System (DEERS).
  • Facilitates utilization management activities by participation in multidisciplinary patient care activities. Initiates/coordinates communication between beneficiaries, team members, internal staff and providers, DoD/civilian providers and ancillary health care workers. Provides feedback regarding utilization review issues within one (1) business day.
  • Reviews and enters first right of refusal referrals into CHCS and database within one (1) business day of the date of the referral.
  • Interfaces with the TRICARE Overseas Program contractor, SGH and multidisciplinary personnel as needed to ensure appropriateness of referrals. Submits referrals from civilian providers to the TRICARE Service Center or TSC for medical necessity and appropriateness review.
  • Performs data collection, trending and analysis to identify patient care requiring intensive management. Refers to case management officials as needed.
  • Receives and makes patient telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. Routinely monitors referral management CHCS queue to ensure patients are being called that do not utilize the Referral Management Center (RMC) walk-in service.
  • Contacts patients in event referral requests are invalid, disapproved by second level review or TRICARE Overseas Program contractor and reschedules patients as soon as possible or instructs patients of other health care options.
  • Answers, completes and/or appropriately forwards patient or provider telephone calls.
  • Coordinates with patient movement office to advise patients of their referral/health treatment options as related to their eligibility per beneficiary status and covered benefits.