Registered Nurse - Utilization Manager

Job Description

Job Description

ABOUT DECYPHER

Decypher is a leading integrator of professional, technology, and management solutions and services. We provide our services globally to Federal, Commercial, Local and State clients. Our employees are our most valuable asset and play an integral role in the success of Decypher and our clients. Working at Decypher is not a job, but a career where your talent and energy is respected, and you can personally make a difference. Decypher invites you to join our professional team. Decypher is an equal opportunity/affirmative action employer committed to diversifying its workforce (M/F/D/V).

DESCRIPTION

Decypher is seeking a Registered Nurse - Utilization Management candidate to support Wright Air Force Base in Dayton, Ohio.

RESPONSIBILITIES

• Assist inpatient discharge planning when needed, as directed. Duties may include
  home safety patient/family interview, attending morning planning meeting, and
  coordinating transfers, home durable medical equipment and/or home care
  services, inpatient rehab, and/or skilled care.
• Develop and implement a comprehensive Utilization Management plan/program
  in accordance with MTF/AF/DHA goals and objectives.
• Perform data/metrics collection on identified program areas; analyzes and trends
  results, including over- and underutilization of healthcare resources and
  ineffective or inefficient delivery of care. Identifies areas for intensive
  management, improved and/or cost containment. Reports utilization patterns,
  provides feedback and makes recommendations in a timely manner.
• Analyze medical referrals/appointments and general hospital procedures by
  monitoring specialty care referrals for appropriateness, covered benefits, and
  authorized surgery/medical procedures, laboratory, radiology, and pharmacy.
• Evaluate clinical practice patterns and trends and provides SGH and clinical areas with feedback.
• Identify and refer potential cases to Disease Management, Case Management,
  Discharge Planning, and the Deployment Availability Working Group.
• Participate in Medical Management, Population Health Working Group, and care
  coordination meetings as assigned.
• Conduct nursing peer review as assigned.
• Educate Patient Centered Medical Home (PCMH) staff on Utilization Management role.
• Assist with PCMH team notification of patients admitted inpatient to civilian
  hospitals or civilian emergency department visits.
• Performs medical necessity reviews to include concurrent review for length of
  stay (LOS) using approved clinical decision tool. Determines medical necessity of
  services ordered or rendered. Communicates negative trends to the Chief of the
  Medical Staff.
• Navigate electronic health record, and TRICARE managed care contractor site.
  Acts as referral approval authority for designated referrals MTF/AF/DHA
  national guidance and standards. Includes processing and validating durable
  medical equipment referrals for PRIME beneficiaries, to include authorization of
  SHCP funds for active-duty beneficiaries. Refers all first-level review failures to
  SGH or designated POC for further review and disposition.
• Verify eligibility of beneficiaries using Defense Eligibility Enrollment Reporting
  System (DEERS). Obtains pertinent information from patients/callers and
  updates electronic medical record, local referral database, and other office
  automation software programs as appropriate and directed.
• Other duties as assigned.

QUALIFICATIONS:

Experience

• A minimum of four (4) years’ experience in discharge planning or case
  management is required for consideration of a candidate with an associate degree in
  nursing.
• Two years full-time experience in utilization management is required for
  graduates with a Bachelor of Science in Nursing.
• Full time employment in a nursing field within the last 36 months is mandatory.

Degree/Education

• Associate Degree (ADN) or a Baccalaureate Degree (BSN) (preferred) program in nursing accredited by a national nursing accrediting agency recognized by the US Department of Education.

Certification

• Basic Life Support (BLS)

Licensure/Registration

• Must maintain a valid, unrestricted, and current registered nursing license

Must be US citizen.

At Decypher we believe that equal opportunity fuels innovation by using the strengths of individual differences. Therefore, we strive to provide a welcoming and inclusive work environment. Decypher is fully committed to a program of equal opportunity for all applicants and employees and will actively carry out all federal and state regulations and executive orders. We apply our equal opportunity policy to all employment decisions.

This job description is not intended to be all inclusive. Therefore, the employee may be requested to perform other reasonable duties as assigned by the immediate supervisor or other management as required.