Nurse (Utilization Management / Referral Management)

Nurse (Utilization Management / Referral Management) Duties

• Ensure that all emergent referrals are submitted to the Managed Care Support Coordinator (MCSC) within same business day and coordinates to expedite patient appointment for all emergent referrals.
• Evaluate the appropriate level of care for referrals and TRICARE Plus network referrals by reviewing the referrals, health care plans and historical care provided to the patient.
• Serve as a resource and assist providers with interpretation of guidelines and criteria for referrals and TRICARE Plus referrals.
• Consult with providers regarding specific anomalies to the network management plan.
• Educate medical staff on proper referral inputs and necessary medical language within referrals.
• Manage day-to-day operations of the Referral Management Center by providing clinical guidance and direction on tracking and processing of referrals.
• Develop and maintain referral guidelines and business rules in coordination with IRMAC. Requirements Conditions of employment
• Appointment may be subject to a suitability or fitness determination, as determined by a completed background investigation.
• This position requires that you obtain and maintain a Basic Life Support (BLS) certification from, or in accordance with, the American Heart Association and American Red Cross. Advanced certification (e.g., ALS) does not supersede BLS.
• All applicants tentatively selected for this position will be required to submit a urinalysis to screen for illegal drug use prior to appointment.
• This position is subject to a pre-employment screening, and random drug testing, to include testing based on reasonable suspicion and testing due to direct involvement with an on-duty accident.
• Immunization screening is required. Hepatitis B immunization is required for all positions with direct patient contact. Applicants may be required to show proof of other immunizations depending on the type of position.
• This position has mandatory seasonal Influenza vaccination requirements and is subject to annual seasonal Influenza vaccinations unless otherwise exempted for medical or religious reasons (documentation of exemption must be provided upon hire).
• This position requires the incumbent to have Tuberculosis testing.
• Applicants must be able to fulfill non-privileged professional credential requirements.
• This position has been designated Mission Essential. In the event of severe weather conditions or other such emergency type situations, the incumbent is required to report to work or remain at work as scheduled to support mission operations.
• This position requires the completion of a pre-employment Physical Examination and an annual examination tafter to ensure the continued, required level of physical health and ability or fitness to perform the duties of the position.
• This position requires the incumbent be able to obtain and maintain a determination of eligibility for a Secret security clearance or access for the duration of employment.

A background investigation and credit check are required. Qualifications

Who May :

US Citizens In order to qualify, you must meet the education and experience requirements described below. Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religious; spiritual; community; student; social). You will receive credit for all qualifying experience, including volunteer experience. Your resume must clearly describe your relevant experience; if qualifying based on education, your transcripts will be required as part of your application. Additional information about transcripts is in this document. Basic Requirement for Nurse (Utilization Management / Referral Management)

Degree:

A graduate or higher level degree, bachelor's degree, associate degree, or diploma from an accredited professional nursing educational program is required. This education must have been accredited by the Commission on Collegiate Nursing Education, Council on Accreditation of Nurse Anesthesia Educational Programs, Accreditation Commission for Midwifery Education, or an accrediting body recognized by the U.S. Department of Education at the time the degree was obtained. (

Note:

You must attach a copy of your transcripts.).

Licensure:

A current, active, full, and unrestricted license or registration as a professional nurse from a State, the District of Columbia, the Commonwealth of Puerto Rico, or a territory of the United States; and you must have passed the National Council Licensure Examination.

Foreign Degree:

Graduates of foreign nursing schools must have completed the Commission on Graduates of Foreign Nursing Schools Certification Program. The certification program consists of a credentials evaluation, the CGFNS Qualifying Exam, and evidence of passing one of the approved English Language Proficiency...Visit the Employer site for more details