Registered Nurse - Utilization Manger
Potomac Healthcare Solutions
Location
Warner Robins, GA | United States
Job description
Registered Nurse – Utilization Management
Robins AFB, GA Position Duties and Responsibilities: - Conduct research in support of improved practice and patient outcomes.
- 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.
Minimum Qualifications: - Bachelor’s Degree in Nursing.
- Graduate from a college or university accredited by Accreditation Commission for Education in Nursing (ACEN), the Commission on Collegiate Nursing Education (CCNE) - OR -Be a graduate from a State Board of Nursing or accredited nursing program.
- Certification: Possess one of the following certifications:
- Commission for Case Manager Certification Certified Case Manager (CCM)
- Certification of Disability Management Specialists Commission: Certified Disability Management Specialist (CDMS)
- Association of Rehabilitation Nurses: Certified Rehabilitation Registered Nurse (CRRN)
- American Board for Occupational Health Nurses Certified Occupational Health Nurse (COHN)
- Certified Occupational Health Nurse-Specialist (COHN-S).
- National Board for Certification in Continuity of Care: Advanced Certification in Continuity of Care (ACCC)
- Commission on Rehabilitation Counselor Certification: Certified Rehabilitation Counselor (CRC)
- American Nurses Credentialing Center Nurse Case Manager (RN-NCM)
- National Academy of Certified Care Managers: Care Manager Certified (CMC)
- One year of experience as a Registered Nurse.
- Possess a current unrestricted license to practice as a Registered Nurse in one of the fifty states, the District of Columbia, the Commonwealth of Puerto Rico, Guam or the U.S. Virgin Islands.
- Must be a US Citizen.
Potomac Healthcare Solutions offers the following benefits: - Medical, Dental and Vision Insurance
- Health Savings Account
- Employer Paid - Basic Life, Accidental Death & Dismemberment and Short-Term Disability
- Long Term Disability
- 401(k) Retirement Savings Plan
- Paid Time Off
- 11 Federal Holidays
- Continuing Education
- Employee Assistance Program
- Wellness Incentives and More
About Potomac Healthcare Solutions: Potomac Healthcare Solutions is an award-winning, dynamic, and rapidly growing healthcare services company with a proven background in providing world-class health services for both government and commercial organizations. We are actively recruiting skilled, caring practitioners to support our rapidly growing program base and supported healthcare facilities. If you would like to be a part of a quality-driven organization and make a difference, we would like to talk to you!
If you do not find interest in this opportunity but know of someone who may, we kindly ask that you refer the individual to Potomac Healthcare Solutions by forwarding this job posting.
We especially welcome employment interest of US Military Veterans with honorable service. Potomac Healthcare Solutions, LLC is an Equal Opportunity Employer Veterans/Disabled. ***This position is contingent upon contract award.
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