LPN -Referral Mgmt Center GTW
Chenega Corporation - Guam

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This Licensed Practical Nurse will provide utilization management activities in the Referral Management Center. Provide outstanding patient care along with duties specified below.

Essential Duties and Responsibilities:
UNIQUE MILITARY HEALTH CARE SYSTEMS/PROCEDURES:
The Composite Health Care System (CHCS) and the newest version, AHLTA, ERAS, ICD-B programs must be utilized for referral management services. Access will be granted by local MTF connectivity and the contractor shall comply with MHS communications and Government IT security standards and policies. The military facility will provide system accounts for MASS personnel after required training and security procedures have been completed by the contractor. If the Military Health Service processes moves away from specified systems, the government will modify the task order accordingly

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Reviews referrals for administrative, clinical completeness and appropriateness. Validates requested medical service, and authorizes surgery/medical procedures, laboratory, radiology, pharmacy, and general hospital procedures and regulations. If unsure coordinates with TRICARE Regional Office Clinical Liaison Nurse and MTF Liaison to remedy errors or uncertainty.

Schedules referral appointments in accordance with Air Force Access to Care Standards within the direct care system or outside the MTF with network/non-network providers. Ensures appointing is done within the Access to Care standards for 90% of all referrals.

Coordinates with specialty referral clinics (internal or external) 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 referral activities by participation in multidisciplinary team activities. Initiates/coordinate communication between beneficiaries, team members, internal staff and providers, network/outside providers and ancillary health care workers. Provides timely, descriptive feedback regarding utilization review issues.

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 Managed Care Support Contractor (MCSC) and multidisciplinary personnel as need to ensure appropriateness of referrals. Submits referrals to non-network providers to TSC for medical necessity/appropriateness review.

Performs data collection and review to identify areas requiring intensive management. Refers to case management officials if needed.

Receives and makes patient telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. Routinely monitors referral management Composite Health Care System (CHCS) queue to ensure patients are being called that do not utilize the RMC walk-in service.

Contacts patients in event referral requests are invalid, disapproved by second level review/MCSC and reschedules patients as soon as possible or instructs patients of other health care options.

Receives and appropriately forwards clinical phone con

Receives and appropriately forwards clinical phone consult requests from patients.

Advises patients of what their referral/health treatment options are as related to their eligibility per beneficiary status and covered benefits. This includes eligibility for travel benefits.

Coordinates with Air Force Aerovac units to make travel arrangements with the Global Patient Movement Requirements Center using the TRANSCOM Regulating and Command and Control Evacuation System as indicated. Ensures Aerovac personnel arrange travel orders and non-medical attendants as required for the patient and the patient is informed.

Advises on Line-of-Duty issues.

Obtains pertinent information from patients/callers, referrals, physician or other officials. Enters data in CHCS, AHLTA, Referral database, and other office automation software programs as appropriate.

Tracks referral reports after appointments are kept. Ensures that results from other MTFs and from network/non-network providers are returned to the referring provider and to the medical record within required timelines and follow up with as necessary. Documents that paper referral results are properly filed in patient’s health record.

Supervision

Requires moderate supervision and may at times supervise others

Minimum Qualifications / Education and/or Experience:
Mandatory knowledge and skills.

Knowledge, skills and computer literacy to interpret and apply medical care criteria, such as InterQual or Milliman Ambulatory Care Guidelines.

The Contractor must have a working knowledge of Ambulatory Procedure Grouping (APGs), Diagnostic Related Grouping (DRGs), International Classification of Diseases-Version 9 (ICD-9), and Current Procedural Terminology-Version 4 (CPT-4) coding.

Possess excellent oral and written communication skills, interpersonal skills, and have working knowledge of computers, specifically the Internet, Microsoft Word, Microsoft Access, Microsoft Excel, and Windows.

Education. Associate of Science in Nursing Program from an approved National League of Nursing.

License cannot be under investigation nor have any adverse action pending from a Nursing State Board or national licensing/certification agency.

Experience - 6 years of clinical nursing experience is required. Previous experience in Utilization Management is not required. Full time employment in a nursing field within the last 36 months is mandatory.

Equivalent combinations of education and experience may be qualifying if approved by the requesting location and the Contracting Officer. If education or experience is used to meet the specialized requirements of this position, it must be directly related to referral/utilization management.

Certificates, Licenses, Registrations, Clearance:
License/certification. Current, active, full, and unrestricted License to practice Nursing in accordance with State Board requirements. Nurse applicants must be a current U.S. licensed Practical Nurse.

A current unrestricted license from any one of the 50 U.S. States, the District of Columbia, The Commonwealth of Puerto Rico, Guam or the U.S. Virgin Islands is acceptable.

Current BLS from American Heart Association.

Computer Skills

Must have working knowledge of a variety of computer software applications as well as experience with Electronic Medical Records.

Competencies

  • To perform the job successfully, an individual should demonstrate the following competencies:
Problem Solving

  • Identifies and resolves problems in a timely manner; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics.
Written Communication

  • Writes clearly and informatively; Able to read and interpret written information including, but not limited to patient medical information.
Diversity

  • Aware of EEO policy; Shows respect and sensitivity for cultural differences; Promotes a harassment-free environment.
Ethics

  • Treats people with respect; Keeps commitments; Inspires the trust of others; Works with integrity and ethically; Upholds organizational values.
Strategic Thinking

  • Adapts strategy to changing conditions.
Planning/Organizing

  • Prioritize and plans work activities; Stays on schedule; Uses time efficiently.
Professionalism

  • Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.
Innovation

  • Meets challenges with resourcefulness; Generates suggestions for improving work; Develops innovative approaches and ideas; Presents ideas and information in a manner that gets others' attention.
Qualifications -

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Language Skills -

Ability to read, analyze; Ability to read and write patient medical records, business correspondence; Ability to effectively present information and respond to questions from patients, families, managers, and the general public.

Mathematical Skills -

Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations as needed.

Reasoning Ability

  • Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to question activities and issues in all functional areas and make sound decisions based on that data.
Physical Demands -

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit and talk or hear. The employee is frequently required to walk; use hands to finger, handle, or feel and reach with hands and arms. The employee is occasionally required to stand; climb or balance and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move equipment and/or patients at times without assistance.

Work Environment -

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.

The employee will normally work in a temperature-controlled office environment, with frequent exposure to patients potentially sick and/or well. With exposure to varied medical equipment as well as electronic office equipment.

The work can be sedentary. However, there may be some physical demands. Requirements include standing, sitting or bending. Individual will be required to walk throughout facility to pick up family practice clinic, medical records, and radiology mail drop offs/signed referrals.

Chenega Corporation is an EOE. AA/M/F/D/V. Native preference under PL930638. We participate in the E-Verify Employment Verification Program.

Qualifications

Minimum Qualifications / Education and/or Experience:
Mandatory knowledge and skills.

Knowledge, skills and computer literacy to interpret and apply medical care criteria, such as InterQual or Milliman Ambulatory Care Guidelines.

The Contractor must have a working knowledge of Ambulatory Procedure Grouping (APGs), Diagnostic Related Grouping (DRGs), International Classification of Diseases-Version 9 (ICD-9), and Current Procedural Terminology-Version 4 (CPT-4) coding.

Possess excellent oral and written communication skills, interpersonal skills, and have working knowledge of computers, specifically the Internet, Microsoft Word, Microsoft Access, Microsoft Excel, and Windows.

Education. Associate of Science in Nursing Program from an approved National League of Nursing.

License cannot be under investigation nor have any adverse action pending from a Nursing State Board or national licensing/certification agency.

Experience - 6 years of clinical nursing experience is required. Previous experience in Utilization Management is not required. Full time employment in a nursing field within the last 36 months is mandatory.

Equivalent combinations of education and experience may be qualifying if approved by the requesting location and the Contracting Officer. If education or experience is used to meet the specialized requirements of this position, it must be directly related to referral/utilization management.

Certificates, Licenses, Registrations, Clearance:
License/certification. Current, active, full, and unrestricted License to practice Nursing in accordance with State Board requirements. Nurse applicants must be a current U.S. licensed Practical Nurse.

A current unrestricted license from any one of the 50 U.S. States, the District of Columbia, The Commonwealth of Puerto Rico, Guam or the U.S. Virgin Islands is acceptable.

Current BLS from American Heart Association.

Computer Skills

Must have working knowledge of a variety of computer software applications as well as experience with Electronic Medical Records.

Job

Medical Services

Primary Location

United States-Guam

Organization

GTW, LLC

Recruiter

Patrick Hoffman

Chenega Corporation - 22 months ago - save job - block
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