Registered Nurse (RN)-Utilization Manager

Portsmouth, VA

Job Category: Nurse Job Number: 2351

Job Description

Currently recruiting a Registered Nurse (RN) Utilization Manager near Portsmouth, Virginia to work in the Medical Management Department of Naval Medical Center Portsmouth. This is a full-time position providing care to military Active-Duty heroes, their families, and. Full-time, 40 hrs./wk., Mon - Sat between 7AM - 7PM.

  • Perform a full range of RN duties including: triage; patient assessment and monitoring; appropriate nursing care, procedures, and treatments; execution of physicians orders; documentation of patient care and observations; and patient education and emotional support.
  • Assist in the design and implementation of activities to increase staff involvement and support of an active and coordinated medical management program. Work in coordination with case management, utilization management, disease management and other members of the health care team. Primary duties shall entail provision of care and treatment of individual patients.
  • Operate and manipulate automated systems such as CHCS, AHLTA, ADS, Essentris, and Clinical Information System (CIS).
  • Alert physicians to significant changes or abnormalities of patients conditions, medical history and specialized treatment plan or protocol.
  • Incorporate utilization review activities using the generally accepted standards and criteria for determining medical necessity, appropriateness, and reasonableness when reviewing the quality, completeness, and adequacy of health care provided to individual patients and patient populations and subsequently with similar patient populations.
  • Promote collaboration and communication among all Medical Management staff, including clinical and business personnel, to promote efficient, effective, and high-quality care and services.
  • Seek to reduce overutilization of Emergency Department (ED) or high cost medical settings by identifying patients with chronic diseases (e.G., diabetes, asthma, etc.) that have a significant impact on health care outcomes and costs.
  • Participate in a progressively integrated approach to provision of services in coordination with Case Management and Disease Management. This approach shall emphasize the importance of facilitating environments, treatments, and procedures that generate opportunities for improved clinical outcomes and/or cost avoidance on both the individual and patient population level.
  • Participate in the development of a utilization management monitoring process that provides the MTF with a warning system that can help identify at-risk patients (e.G. Patients with diabetes, asthma, other chronic conditions, etc.) at the earliest opportunity for intervention, such as during the preadmission and concurrent review processes. For example, patients with specific diseases/ conditions scheduled for admission to the hospital can be identified and referred as potential candidates for Case Management or Disease Management services. As necessary, facilitate proactive discharge planning to help address such patients post- hospitalization needs.
  • Similarly, ensure patients with conditions entailing polypharmacy interventions (e.G., when the patient has been prescribed seven or eight concurrent medications), unexpected admissions, etc., receive appropriate follow up monitoring.
  • Coordinate with multidisciplinary teams to meet the health care needs, including medical and/or psychosocial management of specific patients, and subsequently, similar patient populations.
  • Interface with interdisciplinary teams associated with utilization management activities and serve as a consultant to all disciplines regarding utilization management and related issues.
  • Maintain current knowledge of utilization screening criteria, including but not limited to Milliman, InterQual, Tricare Manual, Medicare benefit manual. Maintain departmental databases and compile statistics from utilization management tracking studies.
  • Maintain adherence to Joint Commission on Accreditation of Health care Organizations (JCAHO), Utilization Review Accreditation Commission (URAC), Case Management Society of America (CMSA) and other regulatory requirements.
  • Provide continual tracking and monitoring of beneficiaries hospitalized in network and non-network facilities and suggests opportunities to recapture care within multiservice market to Director and assists team in providing smooth transition of care.
  • Create daily and periodic reports for Director of Health care Business Operations regarding beneficiaries hospitalized in network and non-network facilities.
  • Serve as a liaison with Managed Care Support Contractor (MCSC) for utilization management-related issues.
  • Degree: Associates Degree of Nursing.
  • Education: Graduate from a college or university accredited by Accreditation Commission for Education in Nursing (ACEN) or The Commission on Collegiate Nursing Education (CCNE). An alternative to this is to graduate from a state accredited professional nursing program.
  • Possess three years of broad-based nursing experience inclusive of a minimum of one yea full-time experience within the last two years as a RN providing utilization management, discharge planning, or case management.
  • Current certification from one of the following: (a) Certified Professional Utilization Review (CPUR) from McKesson Health solutions; or (b) Certified Professional Utilization Management (CPUM) from McKesson Health Solutions; or (c) Health Care Quality and Management Certification (HCQM) from the American Board of Quality Assurance and Utilization Review Physicians; or (d) Certified Professional in Health Care Quality (CPHQ) from the Health Care Certification Board (HQCB), or (e) Commission for Case Manager Certification Certified Case Manager (CCM).
  • Possess and maintain a current unrestricted license to practice as a registered nurse in any state, the District of Columbia, the Commonwealth of Puerto Rico, Guam, or the US Virgin Islands.
  • Must be a U.S. Citizen (for access to Gov' t computer systems)
  • BLS is required.
  • Competitive pay
  • 10 days paid time off per year plus 7 sick days per year
  • 10 paid Federal holidays
  • Health & Welfare allowance mostly covers the cost of health insurance, long and short-term disability, and life insurance
  • Dental and vision plans offered, 401(k)

The Arora Group is an award-winning, Joint Commission-certified nationwide healthcare services company that, for over 30 years, has provided medical care for the men and women who serve our country in the U.S. Armed Forces. Our mission is to provide world-class care and give our healthcare professionals opportunities to improve their skills, learn from the best, and serve the needs of active duty service members, their families, and veterans. EOE AA M/F/Vet/Disability

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