Utilization Review Nurse
Company: Chenega Corporation
Posted on: August 7, 2022
Pediatrics opening in Montgomery, Alabama. This and other rn
jobs brought to you by NursingJobCafe.com
C2 ALASKA, LLC
Maxwell Ambulatory Healthcare Center, Maxwell AFB, AL
The Utilization Review Nurse shall develop and implement a
comprehensive Utilization Management plan/program in accordance
with the local facility's goals and objectives.
- Perform 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.
- Report utilization patterns and provides feedback in a timely
- Analyze 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
- Perform 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
- Review 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.
- Refer all first-level review failures to the SGH or other POC
for further review and disposition.
- Verifie eligibility of beneficiaries using Defense Eligibility
Enrollment Reporting System (DEERS).
- Obtain pertinent information from patients/callers and updates
data in Genesis, local referral database, and other office
automation software programs as appropriate and directed.
- Ensure 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
- Receive and makes patient telephone calls, written, or e-mail
correspondence regarding specialty clinic appointments and
referrals following MTF-specific processes.
- Routinely monitors referral management Genesis queue to ensure
patients referrals are appointed and closed out.
- Ensure Line of Duty paperwork is on file prior to authorization
for all reserve and guard member referrals.
- Keep abreast of MTF and local market services and
- Updates capability report as needed/directed.
- Conduct referral reconciliation report as directed, identifying
all open referrals and provides notification to appropriate
personnel for resolution.
- Monitor active duty, reserve/guard admissions to civilian
hospitals and notifies Case Manager and Patient Administration
Element as required.
- Serve as a liaison with headquarters, TRICARE regional offices,
MTF staff and professional organizations concerning Utilization
- Collaborate 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
- Coordinate and participate in interdisciplinary team meetings,
designated facility meetings, and Care Coordination
- Share knowledge and experiences gained from own clinical
practice and education relevant to nursing and utilization
- Participate in the orientation, education and training of other
staff. May serve on committees, work groups, and task forces at the
- May serve as a member of the Prime Service Area Executive
- 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); CAMH; (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.
- Follow applicable local MTF/AF/DoD instructions, policies and
- Complete medical record documentation and coding, and
designated tracking logs and data reporting as required by local
MTF/AF/DoD instructions, policies and guidance. Complete all
required electronic medical record training, MTF-specific
orientation and training programs, and any AF/DoD mandated
Utilization Management training.
- All services provided shall be in accordance with applicable
DoD, U.S. Air Force installation and facility directives,
guidelines, programs and administrative requirements.
- Other duties as assigned
- Associate's or Baccalaureate degree from a nationally
accredited program in nursing recognized by the Education in
Nursing (ACEN), the Commission of Collegiate Nursing Education
- Maintain 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.
- Shall have provided pediatrician services a minimum of twelve
(12) months within the past two (2) years.
- Must also have at least three to five (3-5) years of experience
in Pediatric Medicine to include residency/fellowship
- Pediatricians must meet all credentialing requirements for the
MTF where they will be providing services.
Knowledge, Skills and Abilities
- Knowledge and ability to effectively apply the following core
case management functions:
a) Assessment: Identification of patients for case management;
comprehensive collection of patient information and medical status;
and continued evaluation of an established plan of care;
b) Planning: Collaboration with the patient, family/caregiver,
primary provider and other members of the health care team for
developing an effective plan of care;
c) Facilitation: Care coordination and communication among all
d) Advocacy: Support for the patient and family/caregivers to
ensure identified education and appropriate, timely care is
- Knowledge of a variety of pharmacological agents used in
patient treatment, the desired effects, side effects, and
complications of their use as well as the accurate administration
of the pharmacologic agent, including dosage calculations as
- Knowledge of the military health care system including TRICARE
health benefits or a working knowledge of the principles of
fee-for-services, preferred provider network and managed care/HMO
organizations is highly desirable.
- Knowledge of the administrative requirements for proper
documentation of patient's condition including disease progress,
acknowledgement of teaching, and follow up care
- Knowledge of medical privacy and confidentiality (Health
Insurance Portability and Accountability Act [HIPAA]), and
accreditation standards of Accreditation Association for Ambulatory
Health Care (AAAHC) and The Joint Commission (TJC), and the
Clinical Practice Guidelines (CPGs)
- 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 demonstrate ability to communicate effectively both orally
and in writing.
- Must be skillful and tactful in communicating with people who
may be physically or mentally ill, uncooperative, fearful,
emotionally distraught, and occasionally dangerous.
- 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; Medical Health System's (MHS) Genesis.
- 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.
- Must demonstrate ability to apply critical thinking skills and
expertise in resolving complicated healthcare, social,
interpersonal and financial patient situations.
- Must possess organization, problem-solving and communication
skills to articulate medical requirements to patients,
families/care givers, medical and non-medical staff in a
professional and courteous way.
- 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
Physical Demands (The physical demands described here are
representative of those that must be met by an employee to
successfully perform the essential functions of this job.
Reasonable accommodations may be made to enable individuals with
disabilities to perform the essential functions.)
- While performing the duties of this Job, the employee is
regularly required to sit and talk or hear. The employee may use
repeated motions that include the arms, wrists, hands and/or
fingers. The employee is occasionally required to walk, stand,
climb, balance, stoop, kneel, crouch, or crawl. The employee must
occasionally lift and/or move up to 25 pounds. Specific vision
abilities required by this job include close vision.
Executive Order 13495, The Non Displacement of Qualified Workers
Under Service Contracts provide first right of refusal to
incumbents on contracts. If the position is accepted by the
incumbent on the job, other application/resume of non-incumbents
will not be reviewed.
Keyphrases: pediatrics jobs, pediatric oncology jobs, pediatric
oncologist jobs, pediatric wound care jobs, urology pediatrics
jobs, pediatric interventional cardiology jobs, pediatric emergency
medicine jobs, pediatric gynecology jobs, pediatric infectious
disease specialist jobs, internal medicine pediatrics jobs,
pediatric medical assistant jobs, pediatrician jobs, neonatal
pediatric specialist jobs, pediatric nephrology jobs, pediatric
nephrologist jobs, pediatric neurology jobs, pediatric nurse
Keywords: Chenega Corporation, Montgomery , Utilization Review Nurse, Healthcare , Montgomery, Alabama
Didn't find what you're looking for? Search again!