Utilization Manager Registered Nurse
Company: Akahi Services
Location: Colorado Springs
Posted on: September 14, 2020
Other opening in Colorado Springs, Colorado. This and other
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Utilization Manager Registered NurseLocation: Colorado Military
Health System, COWork Schedule: Works Monday through Friday. Shifts
may be 8 to 10 hour per day, but will not go over 40 hours a week.
Duties will need to be performed at the Colorado Military Health
System (CMHS) building during core CMHS hours (0600-1700).SUMMARY:
Serves as an analyst of clinical care based upon referrals for
patient care services, medical record information and interaction
with providers and MTF staff. Utilizes criteria-based, systematic
evaluation of the medical necessity, appropriateness, and
efficiency of the use of healthcare services, procedures and
facilities across the continuum of care.DUTIES:
1.1. Provide a comprehensive UM/Case/Care Management program for
all TRICARE eligible beneficiaries.
1.2. Acts as coordinator/liaison with providers, staff and Managed
Care Support Contractor (MSCS) to ensure that actual health care
received is appropriate to meet TRICARE beneficiaries healthcare
1.3. Identifies beneficiaries with complex healthcare needs who may
benefit from alternative treatment modalities, mechanisms, and/or
lower levels of care. Identifies areas of patient care services for
process improvement to maximize utilization capabilities.
1.4. Ensures that the healthcare service is within the scope of
practice and the TRICARE Operations Manual (TOM) access to care
standards for appropriate utilization of services. Performs
utilization management/review for medical necessity for specialty
referrals and appropriate level of care.
1.5. Reviews and initiates recommendations to improve utilization
activities throughout the continuum of care. Provides the
communication link between the providers, staff, and civilian
sectors with regard to utilization review guidelines. Determines if
the services requested are medically appropriate, cost effective,
and provided in the appropriate setting.
1.6. Serves as a resource to and assists primary care managers with
interpretation of guidelines and criteria for patient care and
other systems. Identifies and describes trends using all
appropriate resources/tools. Discusses any problems with the
military medical treatment facility (MTF) providers and civilian
providers and performs necessary follow-up with said providers.
1.7. Reviews requests for patient care services within the Colorado
Springs Multi-Service Market area which includes Evans Army
Community Hospital, the United Sates Air Force Academy, Peterson
AFB, Schriever AFB, and civilian providers for conditions that
require medical care. Optimizes the MHS by redirecting care into
the MTF when appropriate and by optimizing utilization of those
primary and specialty care services in a timely manner.
1.8. Analyze aspects of healthcare provisions within the catchment
areas that affect the financial utilization of the Government by
using professional nursing knowledge of a wide range of nursing
concepts, the ability to function independently with little or no
supervision, and understands all principles and practices.
1.9. Interfaces with HNFS, local, state, and federal agencies
responsible for financing alternatives in healthcare, such as
Medicare, Medicaid, and TRICARE Managed Support Contractor those
beneficiaries may be entitled to.
1.10. Identifies problems with healthcare access and utilization in
both the military and civilian sectors, and recommends
alternatives. Problem areas may include enrollment, outpatient
visits, procedures, emergency department visits, inpatient
admissions, claims, appeals, grievances, and quality management
1.11. Utilizes criteria for the ongoing systematic monitoring and
evaluation of patient care utilization to include tracking
appropriate data. Identifies, documents, analyzes, reports, and
recommends strategies for follow up in issues related to over/under
utilization, high cost, high volume, quality and risk
1.12. Conducts regular training for staff healthcare providers to
teach them important nuances related to writing appropriate
referrals to ensure quality and cost-effective care provided.
1.13. Demonstrate a wide theory base and sound clinical skills to
function as a nursing generalist.
1.14. Demonstrate customer-focused interpersonal skills in order to
interact in an effective manner with physicians, health team
members, community agencies, MTF's Referral Management Centers, as
well as clients and families with diverse opinions, values, and
religious and cultural ideals.
1.15. Knowledge of, and experience with Government regulations,
procedures, limitations and requirements within the scope of their
area highly desired. Working knowledge of latest versions of office
automation software utilized in their area of expertise required;
working knowledge of Composite Health Computer System (CHCS)
desirable.Qualifications:2.1. English Language Requirement. The
contractor shall read, understand, speak, and write English
fluently, and be a United States citizen.
2.2. Formal Education. Certification by a Utilization
Management-specific program such as Certified Professional in
Healthcare Management (CPHM) is desired.
2.3. License: Current licensure to practice nursing in Colorado.
Must be licensed in the jurisdiction in which the MTF is located
(i.e. Colorado). Must maintain an active license or authorizing
document from the state in which they are practicing at no expense
to the government. Copies of license shall be furnished to the
Contracting Officer or designated representative prior to
2.4. Certification: Basic Lifesaver Course (BLS) required.
2.5. Experience: One year of experience in UM and five years of
clinical experience in nursing desired.Akahi Associates
ServicesAkahi Services is a premier provider of healthcare workers
to various military treatment facilities across the United States.
With a corporate office in Honolulu, Hawaii and recruiting office
in San Antonio, Texas we specialize in providing skilled, trained
and highly successful healthcare workers, including RNs, CRNAs,
Physicians, LPN/LVN, Licensed Social Workers, and many more.We have
a strong focus on providing our government customer with quality
and superior service.Akahi Services is an equal opportunity
employer and Minorities, Females, Veterans, and Disabled persons
are encouraged to apply. For further information, please click the
link below to view the EEOIs The Law poster.Qualified applicants
will receive consideration for employment without regard to race,
color, religion, sex, national origin, sexual orientation, gender
identity, disability or protected veteran status.Only qualified
individuals who are being considered will be contacted for an
Keywords: Akahi Services, Colorado Springs , Utilization Manager Registered Nurse, Healthcare , Colorado Springs, Colorado
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