Clinical Nurse - Utilization Management
QuarterLine - Colorado Springs, CO

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QuarterLine provides professional health care staffing services to military hospitals and health clinics across the United States. We are currently seeking a full-time Clinical Nurses - Utilization Management at Peterson Air Force Base in Colorado Springs, Colorado.

Responsibilities:

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 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. May serve as a member of the Prime Service Area Executive Council (PSAEC).
  • 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); 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 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.
The Clinical Nurse - Utilization Management will generally work between the hours of 7:30 am and 4:30 pm, Monday through Friday.

Qualifications:

Education. Shall be a graduate from an associate (ADN) or baccalaureate degree (BSN) program in nursing accredited by a national nursing accrediting agency recognized by the US Department of Education.

License. Maintain an active, valid, current, and unrestricted license (with no limitations, stipulations or pending adverse actions) to practice nursing as a registered nurse in any US state/jurisdiction.

Experience. A minimum of 3 years for ADN or 2 years for BSN full-time experience in utilization management/utilization review or in broad-based clinical nursing. Certification. Certified Professional in Healthcare Management (CPHM) by McKesson or a clinical specialty recognized by American Nurses Credentialing Center -OR- certification eligible with 3 years for ADN or 2 years for BSN experience in utilization management/utilization review or in broad-based clinical nursing.

Must possess knowledge in the following:
  • Must have knowledge of medical privacy and confidentiality (Health Insurance Portability and Accountability Act [HIPAA]), and accreditation standards of Accreditation Association for Ambulatory Health Care (AAAHC), The Joint Commission (TJC), and Clinical Practice Guidelines (CPGs); computer applications/software to include Microsoft Office programs, MS Outlook (e-mail), and internet familiarity; 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 experience in Patient Advocacy, Patient Privacy, and Customer Relations; 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; inpatient unit rounds for clinical data collection; providing documentation for appeals or grievance resolution; applying critical thinking skills and expertise in resolving complicated healthcare, social, interpersonal and financial patient situations; applying problem-solving techniques to articulate medical requirements to patients, families/care givers, medical and non-medical staff in a professional and courteous way.

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QuarterLine is a healthcare professional services company providing a wide range of health solutions and insights to public and private...