Job description
Paid Vacation, Paid Sick Time and 11 Paid Federal Holidays!
- Develops and implements a comprehensive Utilization Management plan/program in accordance with the facility’s goals and 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 the 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/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 the 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.
- Familiarity with the Department of Defense (DoD), Federal, State, non-profit healthcare systems and organizations, including DoD Tri-Service Military Healthcare Systems, TRICARE purchased care system, Medicare, Medicaid and the Veterans Administration (VA) is desired.
- Monday - Friday, 9 hours between 6:30 am and 5:30 pm, with a one-hour lunch
- No weekends or holidays
Minimum ASN; BSN preferred
Minimum 1-year previous Utilization Review/Management experience required;
Licensure: Current, full, active, and unrestricted RN license from any state.
Life Support Certification:
Possess a current AHA or ARC BLS Healthcare Provider certification.
Security:
Must possess the ability to pass a Government background check/security clearance.
About All Medical Resource Foundation:
At All Medical Resource Foundation, our purpose is to connect individuals to resources that meet their specific needs. We focus on connecting healthcare professionals to careers, which allows us to give back to communities.
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