RN - Registered Nurse job Almogordo New Mexico
RN - Registered Nurse job Almogordo New Mexico
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RN - Registered Nurse Job

Employer Name: Signature Performance SpiderID: 7614929
Location: Almogordo, New Mexico Date Posted: 6/1/2018
Wage: Category: Nurses/Nurses Aids
Job Code: 585

Job Description:
Job Description


Registered Nurse

SUMMARY: This Registered Nurse will provide Referral Management (RM) activities include timely processing of Right of First Refusal (ROFR) requests, screening of specialty care referrals, sustaining up-to-date Specialty Clinic Booking Guidance, MTF Capabilities Report, ROFR Reports, maintaining up-to-date MTF/Managed Care Support Contract (MCSC) Memorandums of Understanding (MOUs), comply with Referral and Authorization Business rules, tracking, accounting, and resulting of referrals, and full use of RM information management systems. Individual will conduct reviews for medical necessity, pre-authorization, medical appeals, collection and recovery from insurance carriers, and right of first refusal activities.


Mandatory knowledge and skills.

• Knowledge, skills and computer literacy to interpret and apply medical care criteria, such as InterQual or Milliman Ambulatory Care Guidelines.

• Must possess experience in performing prospective, concurrent, and retrospective reviews to justify medical necessity for medical care to aid in collection and recovery from multiple insurance carriers. Review process includes Direct Care and Purchase Care System referrals, ward rounds for clinical data collection, contacting providers to inform them of dollars lost for missing documentation, and providing documentation for appeals resolution.

• The Contractor must have a working knowledge of Ambulatory Procedure Grouping (APGs), Diagnostic Related Grouping (DRGs), International Classification of Diseases-Version 9 (ICD), and Current Procedural Terminology-Version 4 (CPT-4) coding.

• Possess excellent oral and written communication skills, interpersonal skills, and have working knowledge of computers, specifically the Internet, Microsoft Word, Microsoft Access, Microsoft Excel, and Windows.

Education. Baccalaureate of Science in Nursing Program from an approved National League of Nursing.

License/certification. Current, active, full, and unrestricted License to practice Nursing in accordance with State Board requirements. Nurse applicants must be a current U.S. licensed Registered Nurse.

License cannot be under investigation nor have any adverse action pending from a Nursing State Board or national licensing/certification agency.

Experience. Shall have a minimum of two (2) years broad-based clinical nursing experience in either an inpatient or outpatient care setting within the last three (3) years.

Equivalent combinations of education and experience may be qualifying if approved by the requesting location and the Contracting Officer. If education or experience is used to meet the specialized requirements of this position, it must be directly related to referral/utilization management.

Work Environment/Physical Requirements. The work can be sedentary. However, there may be some physical demands. Requirements include standing, sitting or bending. Individual will be required to walk throughout facility to pick up referral requests, medical records, and radiology results, mail or other completed paperwork.

Job Requirements:

The Composite Health Care System (CHCS) and the newest version, AHLTA, or other ICD-B programs must be utilized for referral management services. Access will be granted by local MTF connectivity and the contractor shall comply with MHS communications and Government IT security standards and policies. The military facility will provide system accounts for MASS personnel after required training and security procedures have been completed by the contractor. If the Military Health Service processes moves away from specified systems, the government will modify the task order accordingly.


• Direct oversight monitoring specialty care referrals for appropriateness, covered benefit, and authorized surgery/medical procedures, laboratory, radiology, pharmacy, and general hospital procedures and regulations to analyze medical referrals/appointments. Proactively collaborates with TRICARE Regional Office Clinical Liaison Nurse and MTF point of contact to address any process issues or concerns. Ensures appointing is done within the Access to Care standards for 90% of all referrals.

• ·Orients and trains other Referral Management Center (RMC) staff. Provides RMC staff in providing, assessing, and improving a wide variety of customer service relations. Ensures referral technicians abide by appointment booking protocols. Assists Flight Commander to ensure Health Service Inspection standards are met at the operational level.

• ·Receives and makes patient telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. Corrects inaccurate authorizations. Assists in locating specialty providers in routine or STAT situations. Routinely monitors referral management Composite Health Care System (CHCS) queue to ensure patients are being called that do not utilize the RMC walk-in service.

• Obtains pertinent information from patients/callers and enters data in CHCS, AHLTA, Referral database, and other office automation software programs as appropriate.

• Acts as an approval authority for all active duty and reserve/guard referrals under the supplemental health care program. Coordinates with SGH for all active, reserve and guard referrals not covered under the TRICARE benefit for approval. Ensures Line of Duty paperwork is on file prior to authorization. Verify eligibility of beneficiaries using Defense Eligibility Enrollment Reporting System (DEERS) and initiates/coordinate communication between beneficiaries, team members, internal staff and providers, network/outside providers and ancillary health care workers.

• Reviews and enters first right of refusal referrals into CHCS and database within one (1) business day of the date of the referral for proper processing in attempts to recapture workload from the network to the MTF. Keeps abreast of facilities services and medical treatment capabilities. Produces reports from databases and updates capability report as needed. Ensures referring provider receives consult summary note within 10 business days after encounter at the MTF. Ensures summaries for all specialty referrals scheduled within the MTF are closed out in the referral database and given to the requesting provider within 72 hours.

• Conducts TRICARE Regional Office reconciliation report daily, identifies all open referrals and ensures resubmission. Ensures all referrals are reviewed and dispositioned in the appropriate manner (both electronically and manually). Monitors active duty, reserve/guard admissions to civilian hospitals and notifies case manager and Patient Administration Element daily. Prepares and submits monthly reports from encounter forms and ad hoc reports. Must meet 80% standard established for consult summary return by reconciling consult summary reports via TRICARE Regional Office portal and referral database.

• Participates in in-services and continuing education programs. Serves as a member of the Prime Service Area Executive Council (PSAEC) or ensures a nurse from the RMC is present. Briefs applicable data/slides to provider staff, executive staff, newcomers, as appropriate. Ensures self or nurse representative is available for all provider/nurse orientation briefings.

• Establishes and maintains good interpersonal relationships with co-workers, families, peers, and other health team members. Submits all concerns through Utilization Management Director; be able to identify, analyze, and make recommendations to resolve problems and situations regarding referrals.

• Be productive and perform with minimal supervisory direction. Be able to independently identify, plan, and carry out projects with consideration for the goals and objectives of the TRICARE Utilization Management Element. Develops detailed procedures and guidelines to supplement established administrative regulations and program guidance. Recommendations are based upon analysis of work observations, review of procedures, and application of guidelines.

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled.

Apply at link: https://recruiting.adp.com/srccar/public/RTI.home?c=1145407&d=ExternalCareerSite&r=5000366425706&rb=JOBSPIDER

Job Criteria:
Start Date:
Position Type: Full-Time Permanent
Years of Experience Required:
Education Required: Bachelors
Overnight Travel:
Vacation Time:

Contact Information:
Contact Name: Mohsin Shaikh Company Type:
City: Findlay
State: Ohio

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