Utilization Management Director jobs in Albany, GA

Registered Nurse – Utilization Management

Moody AFB, GA

Position Duties and Responsibilities:

• 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.                                                              
• 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/DHA/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 the electronic health record, 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 queue in the electronic health record to ensure patients referrals are appointed and closed out.                                                                             
• Ensures Line of Duty paperwork is on file prior to authorization for all reserve and guard member referrals.                                                                                                                                                  
• 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.                                                                                                                                                   
• Follows applicable local MTF/AF/DHA/DoD instructions, policies and guidelines. 
• Completes medical record documentation and coding, and designated tracking logs and data reporting as required by local MTF/AF/DHA/DoD instructions, policies and guidance. 
• Completes all required electronic medical record training, MTF-specific orientation and training programs, and any AF/DHA/DoD mandated Utilization Management training. 
• Ensures a safe work environment, employee safe work habits and patient safety IAW regulatory agencies, infection control policies, and process improvement initiatives. Promote and contribute quality performance, performance improvement programs, and nursing practice in a setting that supports professional practice and sets a positive example; identify and deliver excellence in the delivery of nursing services and care to patients/residents; introduces and disseminates best practices in nursing services. Proactively identifies process issues that could lead to negative patient outcomes and participates in the appropriate safety reporting processes for the facility. 
• Functions as the alternate Special Needs Coordinator (SNC): The SNC is responsible for appropriately screening active-duty family members for medical, psychological and/or educational special needs, enrolling those family members in the Exceptional Family Member Program (EFMP), and documenting the special conditions to facilitate Overseas/Permanent Change of Station clearances/EFMP assignment process according to Air Force Instructions. 
• The SNC works with the Family Member Relocation Clearance Coordinator (FMRCC) as well as the Health Care Integrator and Chief of Medical Staff (SGH). The SNC will also interface with the Exceptional Family Member Program – Family Support (EFMP-FS) to identify appropriate resources for families with special needs and to educate the beneficiary population.

Minimum Qualifications: 

• Graduate from a baccalaureate degree (BSN) program in nursing accredited by a national nursing accrediting agency recognized by the US Department of Education. Certification in relevant specialty, such as Certified Managed Care Nurse through the American Board of Managed Care Nurses or Certified Informatics Nursing, Ambulatory Care Nursing, Medical-Surgical Nursing or Nursing Case Management through the American Nurses Credentialing Center is highly recommended.
• Must have American Red Cross BLS for Healthcare Providers or American Heart Association Basic Life Support (BLS) for Healthcare Providers or American Heart Association Healthcare Provider Course.  
• Must have utilization management, utilization review or case management experience for 24 recent consecutive months. Must have knowledge of medical privacy and confidentiality (Health Insurance Portability and Accountability Act [HIPAA]), and accreditation standards of Accreditation Association for Ambulatory Health Care (AAAHC), The Joint Commission (TJC), and Clinical Practice Guidelines (CPGs) Must have a working knowledge of Ambulatory Procedure Grouping (APGs), Diagnostic Related Grouping (DRGs), International Classification of Diseases-Current Version (ICD), and Current Procedural Terminology-Current Version (CPT) coding; and McKesson (InterQual) and/or Milliman Care Guidelines. Must have experience in Patient Advocacy, Patient Privacy, and Customer Relations. Must be able to perform prospective, concurrent, and retrospective reviews to justify medical necessity for requested medical care and to aid in collection and recovery from multiple insurance carriers Must be able to collect clinical data from inpatient and outpatient sources; provide documentation for appeals or grievance resolution; apply critical thinking skills and expertise in resolving complicated healthcare, social, interpersonal and financial patient situations; apply problem-solving techniques to articulate medical requirements to patients, families/care givers, medical and non-medical staff in a professional and courteous way. 
• Must maintain a full, valid, unrestricted, and current license.  
• Must be a US Citizen.

Potomac Healthcare Solutions offers the following benefits:

• Medical, Dental and Vision Insurance 
• Health Savings Account
• Employer Paid - Basic Life, Accidental Death & Dismemberment and Short-Term Disability  
• Long Term Disability
• 401(k) Retirement Savings Plan  
• Paid Time Off
• 11 Federal Holidays  
• Continuing Education
• Employee Assistance Program
• Wellness Incentives and More

About Potomac Healthcare Solutions:
 Potomac Healthcare Solutions is an award-winning, dynamic, and rapidly growing healthcare services company with a proven background in providing world-class health services for both government and commercial organizations. We are actively recruiting skilled, caring practitioners to support our rapidly growing program base and supported healthcare facilities. If you would like to be a part of a quality-driven organization and make a difference, we would like to talk to you!

If you do not find interest in this opportunity but know of someone who may, we kindly ask that you refer the individual to Potomac Healthcare Solutions by forwarding this job posting. 

We especially welcome employment interest of US Military Veterans with honorable service.

Potomac Healthcare Solutions, LLC is an Equal Opportunity Employer Veterans/Disabled. 
 

***This position is contingent upon contract award.