Registered Nurse – Referral Management/CAMO – Joint Base San Antonio/Lackland, San Antonio, TX  

Leads and directs the utilization review staff and function for a healthcare facility. Determines policies and procedures that incorporate best practices and ensures effective utilization reviews. Manages and monitors both concurrent reviews to ensure that the patient is getting the right care in a timely and cost-effective way and retrospective reviews after treatment has been completed. Provides analysis and reports of significant utilization trends, patterns, and impacts to resources.

Specific tasks include:

  • 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.

· 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.

· 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 CHCS queue to ensure patients referrals are appointed and closed out.

· 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. Provides relevant and timely information to these groups, and assists with decision-making and process improvement. Participates in customer service initiatives, performance and quality improvement measures and medical readiness activities designed to enhance health services.

· 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); Comprehensive Accreditation Manual for Hospitals (CAMH); 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.

· 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.

Qualifications:

  • Must possess an Associate’s Degree of Nursing / Graduate from a college or university accredited by National League for Nursing Accrediting Commission (NLNAC), or The Commission on Collegiate Nursing Education (CCNE).
  • Must possess a current, full, active, and unrestricted license as a Registered Nurse.
  • Must have at least 36 months of total nursing experience in a direct patient care clinical setting. Must have utilization management, utilization review or case management experience for 24 recent consecutive months.
  • Must possess a current active Basic Life Support (BLS) Certification.
  • Excellent organizational skills, attention to detail, and sound skills in written and oral communication is a must.
  • Must be able to read and speak fluent English
  • Must be able to pass a Federal background check

Leading Solutions is committed to hiring and retaining a diverse workforce. We are proud to be an Equal Opportunity Employer. We are committed to ensuring a workplace free of discrimination based on race, color, religion, age, disability, genetic information, sex, sexual orientation, gender identity, or national origin, military or veteran status, and any other basis protected by applicable law.

Leading Solutions is a Service-Disabled Veteran-Owned Small Business (SDVOSB) and Woman-Owned Small Business (WOSB) headquartered in Kissimmee, Florida. The Company provides professional, technical, administrative, and healthcare services to Government and commercial clients. Leading Solutions customer- centric foundation ensures that our leadership and employees meet customer challenges and build trusting partnerships that lay the groundwork for success.

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