Clinical Nurse Utilization Manager - Anticipated
Location: Dyess AFB Texas
Description: Chickasaw Nation Industries is looking of Clinical Nurse Utilization Manager - Anticipated right now, this occupation will be placed in Texas. More details about this occupation opportunity kindly read the description below. The Clinical Nurse Utilization Manager 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. Prioritizes accordingly based on high dollar, high volume, or problem prone diagnoses; 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 right care, at the right time, in the right place, with the right provider, and at the right cost; collaborates with staff, facility departments, and outside agencies to determine the best, most cost-efficient care. Performance will be according to the requirements contained in healthcare standards of practice, Joint Commission on Accreditation of Healthcare Organizations standards (JCAHO), College of American Pathologists (CAP), Health Insurance Portability and Accountability Act (HIPAA), Infection Control, National Fire Protection Association (NFPA) and Health Service Inspection (HSI) standards.
ESSENTIAL DUTIES AND RESPONSIBILITIES Essential duties and responsibilities include the following. Other duties may be assigned.
Responsible for the integration of CNI Core Competencies into daily functions, including: commitment to integrity, knowledge/quality of work, supporting financial goals of the company, initiative/motivation, cooperation/relationships, problem analysis/discretion, accomplishing goals through organization, positive oral/written communication skills, leadership abilities, commitment to Affirmative Action, reliability/dependability, flexibility and ownership/accountability of actions taken. Develops and implements a comprehensive Utilization Management plan/program in accordance with the facility’s goals and 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 pat terns; 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. May serve as a member of the Prime Service Area Executive Council (PSAEC).
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); AMH; (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.
Follows applicable local MTF/AF/DoD instructions, policies and guidelines.
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 any AF/DoD mandated Utilization Management training.
Plans daily activities within the guidelines of company policy, job description and supervisor’s instruction in such a way as to maximize personal output.
Responsible for keeping own immediate work area in a neat and orderly condition to ensure safety of self and co-workers.
Reports any unsafe conditions and/or practices to the appropriate supervisor and human resources. Will immediately correct any unsafe conditions as the best of own ability.
EDUCATION/EXPERIENCE Associate's or Bachelor's in Nursing from accredited program. Must have an active, valid, current, and unrestricted license (with no limitations, stipulations or pending adverse actions) to practice nursing as a Registered Nurse in any US state/jurisdiction. Must have a minimum of 3 years for ADN/2 years for BSN full-time experience in clinical case management working with adults, children, families, seniors and groups.
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).
Must have working knowledge of computer applications/software to include Microsoft Office programs, MS Outlook (e-mail), and internet familiarity is required. The ability to input, extract, and format data from established databases is desired.
Must possess experience in performing prospective, concurrent, and retrospective reviews to justify medical necessity for requested medical care and to aid in collection and recovery from multiple insurance carriers. Review process includes Direct Care and Purchased Care System referrals, inpatient unit rounds for clinical data collection, and providing documentation for appeals or grievance resolution.
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 knowledge and experience, or demonstrate comprehension during training, with software and databases currently employed at the MTF (e.g. Microsoft Office, Access, Excel and PowerPoint; Composite Health Care System [CHCS], Armed Forces Health Longitudinal Technological Application [AHLTA]). Must possess knowledge, skills and computer program literacy to collect and analyze data.
Must have knowledge and experience in Patient Advocacy, Patient Privacy, and Customer Relations.
CERTIFICATES, LICENSES, REGISTRATION CPHM by McKesson or a clinical specialty recognized by the ANCC â€"OR- certification eligible with 3 years for ADN or 2 yrs for BSN full-time experience in utilization management/utilization review or in broad-based clinical nursing Basic Life Support-Provider (BLS)
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If you were eligible to this occupation, please email us your resume, with salary requirements and a resume to Chickasaw Nation Industries.
If you interested on this occupation just click on the Apply button, you will be redirected to the official website
This occupation starts available on: Sun, 08 Jul 2012 07:51:29 GMT
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