• Degree: Associate's Degree in Nursing.
• Education: Graduate from a college or university accredited by
  Accreditation Commission for Education in Nursing (ACEN), the Commission on
  Collegiate Nursing Education (CCNE).
• Experience: One year of experience in Utilization Management after
  graduation.
• Licensure/Registration: Current, complete, active, and unrestricted license to practice

Job Summary:

• 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. Assists RMC staff by providing, assessing, and improving various customer service relations. Ensures referral technicians abide by appointment booking protocols. Assists Flight Commander 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 who do not utilize the RMC walk-in service are being called.
• 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 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 before authorization. Verify beneficiaries' eligibility using Defense Eligibility Enrollment Reporting System (DEERS) and initiate/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 reports as needed. Ensures referring provider receives consult summary note within ten business days after encountering 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 appropriately (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. Meet the 80% standard established for consult summary returns by reconciling consult summary reports via the 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. As appropriate, brief applicable data/slides to provider staff, executive staff, and newcomers. 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.
• Be productive and perform with minimal supervisory direction. Be able to independently identify, plan, and carry out projects with consideration for the goals and objectives of the TRICARE Utilization Management Element. Develops detailed procedures and guidelines to supplement established.