RN-Utilization Management

ERP International is seeking Registered Nurse (RN) Utilization Managers for full-time positions in support of the Mike O'Callaghan Military Medical Center, Nellis AFB, NV. Apply online today and discover more about this outstanding employment opportunity.  www.erpinternational.com

Be the Best!  Join our team of exceptional health care professionals across the nation. Come discover the immense pride and job satisfaction ERP Employees experience in providing care for our Military Members, their Families and Retired Military Veterans!  ERP International is honored to have been named one of The Washington Post’s 2024 Top Workplaces!

* Excellent Compensation & Exceptional Comprehensive Benefits!
* Paid Vacation, Paid Sick Time, Plus 11 Paid Federal Holidays! 

* Medical/Dental/Vision,  LTD/STD/Life and Health Savings Account available, and more!
* Annual CME Stipend and License/Certification Reimbursement!

* Matching 401K!

About ERP International, LLC: ERP is a nationally respected provider of health, science, and technology solutions supporting clients in the government and commercial sectors. We provide comprehensive enterprise information technology, strategic sourcing, and management solutions to DoD and federal civilian agencies in 40 states. Founded in 2006, ERP is headquartered in Laurel, MD and maintains satellite offices in Montgomery, AL and San Antonio, TX - plus project locations nationwide. ERP is an Equal Opportunity Employer - Disability and Veteran.

Work Schedule:

Monday - Friday, 8 to 10 hour shifts, between 7am and 6pm

No Call, No Weekends, No Holidays!

Job Specific Position Duties:

• Provides Utilization Management activities and functions by using MTF specific Quality Improvement processes to identify areas for review from data, suspected problem areas, and input from departments/services within the facility. Identifies gaps between desired and actual program outcomes and develops an action plan to fix gaps. Determines effectiveness of the plan and continually evaluates the impact of implementation. Incorporates applicable utilization review tasks to ensure patients receive the appropriate level of care with the right care, at the right time, in the right place, with the right provider, at the right cost. Collaborates with staff, facility departments and outside agencies to determine the best, most cost-efficient care. Provides cross coverage for those medical management clinical services both inpatient and outpatient which overlap across medical management disciplines to include discharge planning and referrals for case management.
• Utilization management duties incorporate discharge planning to ensure that hospital stays meet the requirements and that a safe discharge guides placement of those patients who are unable to be discharged to home due to need for extended care services.
• Mandatory knowledge and skills:
• Must have knowledge of medical privacy and confidentiality (Health Insurance Portability and Accountability Act [HIPAA]), accreditation standards of Accreditation Association for Ambulatory Health Care (AAAHC), the Joint Commission (TJC), and VA DoD Clinical Practice Guidelines (CPGs).

• Must have a working knowledge of computer applications/software to include Microsoft Office programs (Outlook, Excel, PowerPoint, Publisher and Access, Skype), Tiger Connect and internet familiarity is required.
• 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 experience in Patient Advocacy, Patient Privacy, and Customer Relations.
• Must be able to perform prospective, concurrent, and retrospective reviews to justify medical necessity for requested medical care and to aid in collection and recovery from multiple insurance carriers, including but not limited to Tricare, Medicare, Medicaid, and Health Net Federal Services.
• Must be able to collect clinical data from inpatient and outpatient sources; provide documentation for appeals or grievance resolution; apply critical thinking skills and expertise in resolving complicated healthcare, social, interpersonal, and financial patient situations; apply problem-solving techniques to articulate medical requirements to patients, families/care givers, medical and non-medical staff in a professional and courteous way.
• Communication. Demonstrate ability to utilize verbal and written communication to work as a member of a team employing team building concepts in both multi -and inter-disciplinary setting to maintain medical and utilization management goals. Must be able to provide oral reports/briefings to leadership on utilization management data and make recommendations regarding needed corrections to maximize revenue while decreasing costs associated with admissions; utilize customer service skills via phone, secure messaging and in person contacts to promote positive staff and patient interactions.
• Must be able to interpret data to ensure compliance with requirements for length of stay, obtain needed pre-authorizations and referrals to assist with post hospitalization safe discharge of patients.
• Working knowledge of the military health care system including TRICARE/ Health Net health benefits (is preferred).
• Develops and implements a comprehensive Utilization Management plan/program in accordance with the facility’s goals and strategic objectives.
• Performs data/metrics collection on identified program areas; analyzes and trends results, including over- and under- utilization of healthcare resources. Identifies areas for improvement and cost containment. Reports utilization patterns/trends 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, pharmacy and durable medical equipment.
• 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 guidelines and standards. Refers all first-level review failures to the Chief of Medical Staff (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 MHS GENESIS, 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. Collaborates, coordinates with TOPA and Referral Management Director when needed in accordance with TRICARE Operations manual.
• Receives and makes patient telephone calls, written, or e-mail correspondence regarding specialty clinic appointments and referrals following MTF-specific processes.
• Monitors routinely referral management MHS GENESIS queue to ensure patients referrals are appointed and closed out per MTF guidelines.
• 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, including all eligible beneficiaries, to civilian hospitals and notifies Clinical Nurse Case Manager and Patient Administration Element as required.
• Serve as a liaison with headquarters (99th ABW) TRICARE regional offices, Manage Care Support Team, 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 Integrator Consultants, Medical Management team, SGH (Chief of Medical Staff), Coders/Coding Auditors, 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, discharge planning meetings/rounds 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. Provides relevant and timely information to these groups and assists with decision-making and process improvement. Participates in customer service initiatives, performance and quality improvement measures and medical readiness activities designed to enhance health services.
• 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);
Comprehensive Accreditation Manual for Hospitals (CAMH); 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.

• Adheres to applicable local MTF/AF/DoD, DHA, VA instructions, policies and guidelines.
• Completes medical record documentation and coding, and designated tracking logs and data reporting as required by local MTF/AF/DoD, DHA, VA 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. Includes (but is not limited to) all training on the use of utilization management data base applications (i.e. Defense Health Agency (DHA),,Military Health System Population Health Portal (MHSPHP) CarePoint 4G , AFMS , TOPA applications to obtain necessary data for Preventative Healthcare Screening, Healthcare Effectiveness Data and Information Set (HEDIS).
• Ensures a safe work environment, employee safe work habits and patient safety IAW regulatory agencies, infection control policies, and process improvement initiatives. Promote and contribute quality performance, performance improvement programs, and nursing practice in a setting that supports professional practice and sets a positive example; identify and deliver excellence in the delivery of nursing services and care to patients/residents; introduces and disseminates best practices in nursing services. Proactively identifies process issues that could lead to negative patient outcomes and/or delays in discharge placement and participates in the appropriate safety reporting processes for the facility.

Minimum Qualifications:

* Degree/Education: Shall be a graduate from a baccalaureate degree program in nursing with a BSN, accredited by a national nursing accrediting agency recognized by the US Department of Education, the Commission on Collegiate Nursing Education (CCNE), or Accreditation Commission for Education in Nursing (ACEN).
* Experience: Must have at least 3 years of total nursing experience in a direct patient care clinical inpatient and outpatient setting. Must have utilization management experience for 2 years in recent consecutive months including case management care and discharge planning for patients ranging in age from 0-95 years and including children, families, seniors, and groups.

* Licensure/Certification: Active, unrestricted Registered Nursing license to practice nursing in a State, District of Columbia, the Commonwealth of Puerto Rico, or a territory of the United States. Certification (preferred) or eligible in a relevant specialty, such as Certified Managed Care Nurse through the American Board of Managed Care Nursing or the American Association of Managed Care Nurses or Certified Informatics Nursing, Ambulatory Care Nursing, Medical-Surgical Nursing or Nursing Case Management through the American Nurses Credentialing Center.

* Life Support Certification: BLS from American Red Cross or American Health Association.
* Security: Must possess ability to pass a Government background check/security clearance.