Registered Nurse (RN) - Utilization Management
Company: FEDERAL STAFFING RESOURCES
Location: Colorado Springs
Posted on: November 11, 2018
Case Management opening in Colorado Springs, Colorado. This and other rn jobs brought to you by NursingJobCafe.com Registered Nurse (RN) - Utilization Management job in Colorado Springs, CO. 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.Fantastic PTO accrual rateCompetitive CompensationBenefit Package (health, dental, and vision plans)Registered Nurse (RN) - Utilization Management Job Overview:
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, at the right cost. Collaborates with staff, facility departments, and outside agencies to determine the best, most cost-efficient careDevelops 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 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. Registered Nurse (RN) - Utilization Management Job Qualifications:
BSN preferredGraduate from a NLN or AACN accredited college or universityRN licenseCertification by a Utilization Management-specific program such as Certified Professional in Healthcare Management (CPHM) is desired.BCLSComputer competency APGs, DRGs, ICD, CPT, InterQual, and/or Milliman Care Guidelines
One year of previous experience in Utilization Management is required. Employment in a nursing field within the last 12 months is mandatory. 6 years of active clinical nursing practice is desired.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.Familiarity with Department of Defense (DoD), Federal, State, non-profit healthcare systems and organizations, to include DoD Tri-Service Military Healthcare Systems, TRICARE purchased care system, Medicare, Medicaid and the Veterans Administration (VA) is desired. Position contingent on contract award for 1/2019. Incumbents HIGHLY encourage to contact us! Come join our team of healthcare professionals! Keyphrases: medical case management jobs, case manager jobs, case manager consultant jobs, case management consultant jobs, geriatric case management jobs, case management nursing jobs, nurse case manager jobs
Keywords: FEDERAL STAFFING RESOURCES, Colorado Springs , Registered Nurse (RN) - Utilization Management, Executive , Colorado Springs, Colorado
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