Registered Nurse (RN) - Utilization Management
Company: FEDERAL STAFFING RESOURCES
Location: Great Falls
Posted on: March 30, 2019
Case Management opening in Great Falls, Montana. This and other rn
jobs brought to you by NursingJobCafe.com Contract position with a
Spring 2019 start date. Position contingent on contract award.
Incumbents highly encourage to contact us. Come join our team of
healthcare professionals! Registered Nurse (RN) - Utilization
Management job in Great Falls, Montana.
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.Monday-FridayDaysFantastic PTO
accrual rateCompetitive CompensationBenefit Package (health,
dental, and vision plans)Registered Nurse (RN) - Utilization
Management Job Overview:
- Develops and implements a comprehensive Utilization Management
plan/program in accordance with the facility's goals and
- Performs data/metrics collection on identified program areas;
analyzes and trends results, including over- and under utilization
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
- 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
- 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
- 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
- Ensures Line of Duty paperwork is on file prior to
authorization for all reserve and guard member referrals.
Registered Nurse (RN) - Utilization ManagementJob Qualifications:
- ADN or BSN
- Graduate from a NLNAC or CCNE accredited college or
- RN Licensure
- Minimum of 3 years for ADN or 2 years for BSN full-time
experience in utilization management/utilization review or in
broad-based clinical nursing
- Board Certification: Certified Professional in Healthcare
Management (CPHM) by McKesson or a clinical specialty recognized by
American Nurses Credentialing Center -OR- certification eligible
with 3 years for ADN or 2 years for BSN experience
- Computer competency
- HIPAA, TJC, CPGs, AAAHC, APGs, DRGs, ICD, CPT coding; and
McKesson (InterQual) and/or Milliman Care Guidelines.
- Experience in Patient Advocacy, Patient Privacy, and Customer
Relations; 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;
inpatient unit rounds for clinical data collection; providing
documentation for appeals or grievance resolution; applying
critical thinking skills and expertise in resolving complicated
healthcare, social, interpersonal and financial patient situations.
Position contingent on contract award. Incumbents HIGHLY encourage
to contact us! Come join our team of healthcare professionals!
Keyphrases: medical case management jobs, case manager jobs, case
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Keywords: FEDERAL STAFFING RESOURCES, Great Falls , Registered Nurse (RN) - Utilization Management, Healthcare , Great Falls, Montana
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