FSR (Federal Staffing Resources)
  • Scott AFB, IL, USA
  • Full Time

 

Registered Nurse RN) - Utilization Management job in Belleville, Illinois. 

The Registered Nurse (RN) - Utilization Management job is within the military medical system and is a civilian position. Civilian and military personnel work together in the extensive military medical system. The hospitals and medical clinics provide services to the active duty military service members, military retirees, and their families and provide a full range of medical services. 

Our employees are our best assets! Come join our team of healthcare professionals where you are valued.

  • Monday-Friday
  • Days only!
  • Fantastic PTO accrual rate
  • Competitive Compensation
  • Benefit Package (health, dental, and vision plans)
  • Dedication Program Manager to support your employment 

Registered Nurse (RN) - Utilization Management Job Overview:

  • Direct oversight monitoring specialty care referrals for appropriateness, covered benefit, and authorized surgery/medical procedures, laboratory, radiology, pharmacy, and general hospital procedures and regulations to analyze medical referrals/appointments.
  • Proactively collaborates with TRICARE Regional Office Clinical Liaison Nurse and MTF point of contact to address any process issues or concerns.
  • Ensures appointing is done within the Access to Care standards for 90% of all referrals. 
  • Orients and trains other Referral Management Center (RMC) staff.
  • Provides RMC staff in providing, assessing, and improving a wide variety of customer service relations.
  • Ensures referral technicians abide by appointment booking protocols. Assists Flight Commander to ensure Health Service Inspection standards are met at the operational level. 
  • Receives and makes patient telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. Corrects inaccurate authorizations.
  • Assists in locating specialty providers in routine or STAT situations.
  • 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. 
  • Obtains pertinent information from patients/callers and enters data in CHCS, AHLTA, MHS GENESIS, Referral database, and other office automation software programs as appropriate. 
  • Acts as an approval authority for all active duty and reserve/guard referrals under the supplemental health care program.
  • Coordinates with SGH for all active, reserve and guard referrals not covered under the TRICARE benefit for approval.
  • Ensures Line of Duty paperwork is on file prior to authorization.
  • Verify eligibility of beneficiaries using Defense Eligibility Enrollment Reporting System (DEERS) and initiates/coordinate communication between beneficiaries, team members, internal staff and providers, network/outside providers and ancillary health care workers. 
  • Reviews and enters first right of refusal referrals into CHCS and database within one (1) business day of the date of the referral for proper processing in attempts to recapture workload from the network to the MTF.
  • Keeps abreast of facilities services and medical treatment capabilities.
  • Produces reports from databases and updates capability report as needed.
  • Ensures referring provider receives consult summary note within 10 business days after encounter at the MTF.
  • Ensures summaries for all specialty referrals scheduled within the MTF are closed out in the referral database and given to the requesting provider within 72 hours. 
  • Conducts TRICARE Regional Office reconciliation report daily, identifies all open referrals and ensures resubmission.
  • Ensures all referrals are reviewed and dispositioned in the appropriate manner (both electronically and manually).
  • Monitors active duty, reserve/guard admissions to civilian hospitals and notifies case manager and Patient Administration Element daily.
  • Prepares and submits monthly reports from encounter forms and ad hoc reports. 
  • Establishes and maintains good interpersonal relationships with co-workers, families, peers, and other health team members. Submits all concerns through Utilization Management Director; be able to identify, analyze, and make recommendations to resolve problems and situations regarding referrals. 

Registered Nurse (RN) - Utilization Management Job Qualifications:

  • BLS
  • RN Licensure: Current, full, active, and unrestricted. Any U.S. state.
  • Knowledge, skills and computer literacy to interpret and apply medical care criteria, such as InterQual or Milliman Ambulatory Care Guidelines. 
  • Experience in performing prospective, concurrent, and retrospective reviews to justify medical necessity for medical care to aid in collection and recovery from multiple insurance carriers. Review process includes Direct Care and Purchase Care System referrals, ward rounds for clinical data collection, contacting providers to inform them of dollars lost for missing documentation, and providing documentation for appeals resolution. 
  • Working knowledge of APGs, DRGs), ICD and CPT-4 coding
  • 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. 
  • Baccalaureate of Science in Nursing (BSN) Program from an approved National League of Nursing
  • Six years of clinical nursing experience is required.
  • One year of previous experience in Utilization Management
  • Full time employment in a nursing field within the last 36 months 
  • 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. 

 

 Position contingent on contract award. Incumbents HIGHLY encourage to contact us! Come join our team of healthcare professionals! 

 


www.FSRpeople.com

FSR provides healthcare professionals to government healthcare facilities supporting active military service members, retirees, and their families nationwide. Since 2004, FSR has matched talented individuals to organizations to create mutually beneficial, sustainable partnerships. FSR is a well-established, award winning organization built with committed professionals who have a unified vision of helping others to succeed and thrive.

We invite you to join our team and grow with us!

FSR is a woman-owned, minority, small business based out of Maryland.

 

Federal Staffing Resources dba FSR is an Equal Opportunity Employer: disability/veteran/military spouse

This contractor and subcontractor shall abide by the requirements of 41 CFR 60-1.4(a), 60-300.5(a) and 60-741.5(a). These regulations prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, sexual orientation, gender identity or national origin. Moreover, these regulations require that covered prime contractors and subcontractors take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status or disability.

FSR (Federal Staffing Resources)
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