FSR (Federal Staffing Resources)
  • Tampa, FL, USA
  • Full Time

 

Registered Nurse (RN) - Utilization Management job in Tampa, Florida. 

The  job is a civilian position within the military medical system. Civilian and military personnel work together providing a full range of services to the active duty military service members, military retirees, and their families.

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

  • Monday-Friday day schedule
  • Holidays off
  • Fantastic PTO accrual rate
  • Competitive Compensation
  • Benefit Package (health, dental, and vision plans)

Registered Nurse (RN) - Utilization Management Job Overview:

  • Timely processing of Right of First Refusal; screening of specialty care referrals; sustaining up-to-date Specialty Clinic Booking Guidance; MTF Capabilities Report; ROFR Reports; maintaining up-to-date MTF/Managed Care Support Contract (MCSC) Memorandums of Understanding (MOUs); and comply with Referral and Authorization Business rules, tracking, accounting, and resulting of referrals.
  • Conduct reviews for medical necessity, pre-authorization, medical appeals, collection and recovery from insurance carriers, and right of refusal activities.
  • Work with the executive staff of clinical operations, resource management, medical records, patient administration, and the quality division within the MTF to provide the appropriate level of resources and minimize cost for beneficiaries. 
  • Monitors specialty care referrals for appropriateness, covered benefit, and authorizedsurgery/medical procedures, laboratory, radiology, pharmacy, and general hospital procedures and regulations to analyze medical referrals/appointments. 
  • Assist with orientation and training of other Medical Management staff and assist inproviding, assessing, and improving a wide variety of customer service relations.
  • 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. Routinely monitors referral management Composite Health Care System (CHCS) queue to ensure patients are being called that do not utilize the Referral Management Center walk-in service.
  • Obtains pertinent information from patients/callers and enters data in CHCS, AHLTA, 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 andupdates capability report as needed.
  • Develops and implements a comprehensive Utilization Management plan/program for beneficiaries within MTF's goals and objectives.
  • Reviews previous and present medical care practices as needed for patterns, trends, or incidents of under or over utilization of hospital resources incidental to medical care provided to beneficiaries. 
  • Analyzes data and prepares reports to describe resource utilization patterns. Briefs applicable data/slides to provider staff,executive staff, newcomers, as appropriate. Identifies areas requiring intensive management or areas for improvement. 
  • Maintains reports on which cases have been denied or received reduced third partypayments and reports provider profiles to the Medical Management Director/ChiefMedical Services for corrective action. 
  • Serves as a liaison with higher headquarters, TRICARE Regional Office, MTF national accreditation organization, professional organizations, and communityhealth care facilities concerning Utilization Management. 

Registered Nurse (RN) - Utilization Management  Job Qualifications:

  • BLS
  • Baccalaureate of Science in Nursing Program from an approved National League of Nursing
  • Six years of clinical nursing experience
  • One year of previous experience in Utilization Management
  • Full time employment in a nursing field within the last 36 months

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

  • RN Licensure/Registration: Current, active, full, and unrestricted. 
  • 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, Diagnostic Related Grouping (DRGs), International Classification ofDiseases-Version 9 (ICD), and Current Procedural Terminology-Version 4 (CPT-4) coding.
  • Possess excellent oral and written communication skills and interpersonal skills
  • Working knowledge of computers, specifically the Internet, Microsoft Word, Microsoft Access, Microsoft Excel, and Windows. 

 

 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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