Job Description
NURSE – REFERRAL MANAGEMENT
SITE OF SERVICE:
Anderson Air Force Base, Guam
Full Time
POSITION QUALIFICATION/REQUIREMENTS:
Education: Vocational Nurse Program OR Baccalaureate of Science in Nursing Program from an approved National League for Nursing Accrediting Commission (NLNAC) or the Commission on Collegiate Nursing Education (CCNE)
Cardiac Certifications: Must have the following hands-on certification through the American Heart Association or American Red Cross: Basic Life Support (BLS)
Experience: Possess a minimum of 2-years of clinical nursing experience is required. One year of previous experience in Utilization Management is required. Full time employment in a nursing field within the last 36 months is mandatory. 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.
Licensure: Current, full, active, and unrestricted license to practice as a Practical OR Registered Nurse in any one of the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, Guam or the U.S. Virgin Islands.
U.S. Citizenship: Shall be a U.S. citizen
English Language Requirement: Shall be able to read, write, speak and understand English well enough to effectively communicate with all patients and other health care providers.
Physical Capability: Shall be physically capable of standing and/or sitting for extended periods of time and physically capable of performing all services required under the contract.
DUTIES:
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 Leadership 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, MHS GENESIS, 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.
HOURS:
Services shall be provided Monday through Friday, between the hours of 0730 - 1630 for an 8.5-hour shift period to include an uncompensated 30-minute meal break, respectively. In no instance will the HCW be required to provide excess of 80 hours per two-week period. Specific hours shall be scheduled 30 days in advance by the Department Head or a designated Government Representative.
No weekends, Federal holidays or scheduled base closure days.
SPECIAL REQUIREMENTS/SKILLS
Must be comfortable in a fast-paced, dynamic environment. Must be able and willing to reprioritize on short notice and work on multiple simultaneous projects. Flexible and able to work with various personalities. Teamwork skills required. Time management skills required. The ability to meet deadlines in a deadline intensive environment is essential. High level of adaptability and willingness to embrace change in a fast-paced, demanding environment.
LUKE is an Equal Opportunity employer
Links: To learn more about LUKE please visit our website at:
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Job Tags
Full time, Contract work, Work at office, Flexible hours, Shift work, Monday to Friday,