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RN - Utilization Management
Ref No.: 15-00615
Category: Registered Nurse
Location: Grand Forks, North Dakota
Start Date: 08/28/2015
RN - Utilization Management
A community where promises are kept…

The Community - Grand Forks, ND
Grand Forks is the third-largest city in the State of North Dakota (after Fargo and Bismarck). Grand Forks, along with its twin city of East Grand Forks, Minnesota, forms the center of the Grand Forks, ND-MN Metropolitan Statistical Area, which is often called Greater Grand Forks or The Grand Cities. Its location at the fork of the Red River and the Red Lake River gives the city its name. Historically dependent on local agriculture, the city's economy now encompasses higher education, defense, health care, manufacturing, food processing, and scientific research. Grand Forks is served by Grand Forks International Airport and Grand Forks Air Force Base, while the city's University of North Dakota is the oldest institution of higher education in the state. The Alerus Center and Ralph Engelstad Arena host athletic and other events, while the North Dakota Museum of Art and Chester Fritz Auditorium are the city's largest cultural venues.
 
The Grand Fork Promise is key to getting to know about the community, you can read more HERE.

Grand Forks Air Force Base
Grand Forks Air Force Base is located in the heart of the Red River Valley at the junction of the Red Lake River and the Red River of the North. The quality of life in this community has been ranked by Money Magazine as one of the top communities in the nation. Grand Forks AFB plays a central role in the nation's defense. It is home to the 319th Air Base Wing, the only base in Air Mobility Command to receive remotely piloted aircraft systems, such as the RQ-4 Global Hawk Unmanned Aerial Vehicle.

 
Requirements (duties include but are not limited to)
  • 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 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. 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); 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.
Additional Requirements
  • Provides case management, care coordination for outpatient care settings.
  • Assists service members and/or veterans, family members and caregivers with receiving the most appropriate options and services to meet their complex health care needs. This includes, but is not limited to, acute, chronic, multiple, complex, catastrophic, or life-threatening illnesses.
  • Coordinates care with multiple providers across all levels and sites of care.
  • Addresses psychosocial, as well as nursing and medical needs of patients and their families/caregivers through participation in multidisciplinary patient care management practice.
  • Evaluates care and outcomes to ensure timely and appropriate provision of services.
  • Must have the knowledge and skills to effectively apply the following core case management functions:
    • Assessment: Identification of patients for case management; comprehensive collection of patient information and medical status; and continued evaluation of an established plan of care.
    • Planning: Collaboration with the patient, family/caregiver, primary provider and other members of the health care team for developing an effective plan of care.
    • Facilitation: Care coordination and communication among all involved parties.
    • Advocacy: Support for the patient and family/caregivers to ensure identified education and appropriate, timely care is received.
  • Coordinates and participates in interdisciplinary team meetings, designated facility meetings, and Care Coordination meetings.
  • Shares knowledge and experiences gained from own clinical nursing practice and education relevant to nursing and case management.
  • 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 AF/DoD mandated Case Management training
Qualifications
  • 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).
  • Certified/certification eligible in relevant specialty, such as Certified Managed Care Nurse through the American Board of Managed Care Nurses or Certified Informatics Nursing, Ambulatory Care Nursing, Medical-Surgical Nursing or Nursing Case Management through the American Nurses Credentialing Center.
  • Certified Case Manager by Commission for Case Management (CCM) or American Nurses Credentialing Center (ANCC) -OR- certification eligible with 3 years of experience for ADN or 2 years' experience for BSN in full time clinical case management with children, families, seniors, or groups.
  • Must have a working knowledge of computer applications/software to include Microsoft Office programs, MS Outlook (e-mail) and internet familiarity.
  • 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.
  • 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.
  • Must have at least 36 months of total nursing experience in a direct patient care clinical setting. Must have utilization management, utilization review or case management experience for 24 recent consecutive months.
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