Registered Nurse- Utilization Management

CentralCare Inc San Antonio, TX 78226, US

Join our team at Randolph Air Force Base and become part of a mission-driven healthcare team dedicated to providing exceptional support to active-duty service members, retirees, and their families. If you're looking for a rewarding career with excellent benefits and the opportunity to serve those who serve our nation, we'd love to hear from you!

Registered Nurse –Utilization Management - JBSA - Randolph

Location: San Antonio, TX

Degree/Education Requirements:

Bachelor of Science in Nursing

Graduate from a college or university accredited by National League for Nursing

Accrediting Commission (NLNAC), or The Commission on Collegiate Nursing Education (CCNE).

Required Experience:

Three years of experience in nursing
Must have knowledge of medical privacy and confidentiality (Health Insurance
Portability and Accountability Act [HIPAA]), and accreditation standards of
Accreditation Association for Ambulatory Health Care (AAAHC)
Must have a working knowledge of computer applications/software to include Diagnostic Related Grouping (DRGs).
Must be able to collect clinical data from inpatient and outpatient sources; provide documentation for appeals or grievance resolution; apply critical thinking skills and expertise in resolving complicated healthcare, social, interpersonal, and financial patient situations;

Licensure/Registration: Current, full, active, and unrestricted license to practice as a Registered Nurse.

Job Responsibilities.:

Coordinate patient care in collaboration with a wide array of healthcare professionals.
Ensure compliance with standards of care and practice in accordance with all established policies, procedures, and guidelines used in the MTF.
Direct and supervise care provide by other healthcare professionals
Make referral appointments and arrange specialty care as appropriate.
Conduct research in support of improved practice and patient outcomes.
Develops and implements a comprehensive Utilization Management plan/program in accordance with the facility's goals and strategic objectives.
Performs data/metrics collection on identified program areas; analyzes and trends results, including over- and underutilization of healthcare resources. Identifies areas for improvement and cost containment.
Reports utilization patterns
Analyzes medical referrals/appointments and general hospital procedures and regulations by monitoring specialty care referrals for appropriateness, covered benefits, and authorized surgery/medical procedures, laboratory, radiology, and pharmacy.
Performs medical necessity review for planned inpatient and outpatient surgery; and performs concurrent review to include length of stay (LOS) for the facility's inpatients using appropriate criteria.
Reviews previous and present medical care practices for patterns; trends incidents of under or over- utilization of resources incidental to providing medical care.
Acts as referral approval authority for designated referrals
Verifies eligibility of beneficiaries using Defense Eligibility Enrollment Reporting System (DEERS).
Obtains pertinent information from patients/callers and updates data MHS Genesis, local referral database, and other office automation software programs.
Make a Difference Where It Matters
Join Central Care Incorporated at Randolph Air Force Base and make a difference—one patient at a time.
About Central Care Inc.
Central Care Incorporated is an equal opportunity employer. We encourage applications from candidates of all backgrounds and experiences to apply.

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