Registered Nurse - Utilization Management

Overview

ERP International is seeking a Utilization Management Registered Nurse (RN) for a full-time position supporting the 2d Medical Group, Barksdale AFB, LA 

 

Be the Best!  Join our team of exceptional health care professionals across the nation. Come discover the immense pride and job satisfaction ERP Employees experience in providing care for our Military Members, their Families and Retired Military Veterans!  ERP International is honored to have been named one of The Washington Post’s 2024 Top Workplaces!

* Excellent Compensation & Exceptional Comprehensive Benefits!* Paid Vacation, Paid Sick Time, Plus 11 Paid Federal Holidays! 

* Medical/Dental/Vision, STD/LTD/Life, Health Savings Account available, and more!* Annual CME Stipend and License/Certification Reimbursement!

* Matching 401K!

 

About ERP International, LLC: ERP is a nationally respected provider of health, science, and technology solutions supporting clients in the government and commercial sectors. We provide comprehensive enterprise information technology, strategic sourcing, and management solutions to DoD and federal civilian agencies in 40 states. Founded in 2006, ERP is headquartered in Laurel, MD and maintains satellite offices in Montgomery, AL and San Antonio, TX - plus project locations nationwide. ERP is an Equal Opportunity Employer - Disability and Veteran.

Responsibilities

Schedule:

Monday - Friday, 9 hours between 7:00am and 5:00pm, with a one-hour lunch

No Weekends or Holidays

 

Duties: The duties include, but are not limited to the following;

• Assist with orientation and training of other Medical Management staff and assist inproviding, assessing, and improving a wide variety of customer service relations. AssistsMTF officials to ensure Unit Effectiveness Inspection standards are met at the operationallevel.
• Assists in the development and implementation of a comprehensive UtilizationManagement plan/program for beneficiaries within MTF’s goals and objectives. Thisplan is based on using the 12-step approach as described in the DoD MedicalManagement Guide.
• Establish procedures for conducting reviews, including identification of types ofhealthcare services for which preauthorization or concurrent review will be required.Reviews previous and present medical care practices as needed for patterns, trends, orincidents of under or over utilization of hospital resources incidental to medical careprovided to beneficiaries.
• Plans and performs reviews IAW established indicators and guidelines to providequality cost-effective care. Ensures identified patient needs are addressed promptly withappropriate decisions. Provides timely, descriptive feedback regarding utilization reviewissues. Use the same generally accepted standards, norms, and criteria to review thequality, completeness, and adequacy of healthcare provided within the MTF, as well asits necessity, appropriateness, and reasonableness.
• Adhere to the established standardized DCS appeal process for resolvingbeneficiaries’ request for reconsideration of MTF denials of care based on medical necessity determinations in accordance with References (e) and (o). After following the directed methodology for appeals, the MTF will also adhere to its respective Service or joint commands’ process for intermediate notification, if any, prior to progressing from the internal to external level of appeals.
• Adhere to the MHS and Military Department’s or Joint Medical Commands’ referral management policies to manage internal and external referrals. Incorporate UM strategies as part of the referral management center’s routine processes. Ensure processes monitor, manage, and optimize demand or capacity (access).
• Collaborate with the PCMH team to develop performance measures and processes for clinically important conditions, as determined by the PCMH teams and MTF leadership. These clinically important conditions should include but may not be limited to high -cost, high-volume, or problem-prone diagnoses, procedures, services, and beneficiaries that utilize healthcare at higher rates than average and who may benefit from intervention and more intense care coordination. Performs data/metric collection. Analyzes data and prepares reports to describe resource utilization patterns. Briefs applicable data/slides to provider staff, executive staff, newcomers, as appropriate. Identifies areas requiring intensive management or areas for improvement.
• Maintains reports on which cases have been denied or received reduced third party payments and reports provider profiles to the MTF management for corrective action.
• Serves as a liaison