The Referral Management Registered Nurse will provide RM activities which include timely review of ROFR requests, review of specialty care referrals, sustaining up-to-date Specialty Clinic Referral Review tools and booking guidance, comply with Referral and Authorization Business rules, tracking, and resulting of referrals, and full use of RM information management systems. Individual will conduct reviews for capacity, capability, medical necessary, deferral to network, and right of first refusal activities.
MANDATORY KNOWLEDGE AND SKILLS:
- Knowledge, skills and computer literacy to interpret and apply medical care criteria, such as InterQual, Milliman Ambulatory Care Guidelines, Specialty Referral Guidelines (SRGs) or other evidence-base guidelines identified by the MHS.
- The Contractor must have a working knowledge of medical terminology, MHS, VA-DOD Sharing Program, TRICARE, HIPAA, release of medical information. Demonstrates ability to manage a high-performing and efficient team.
- Possess excellent oral and written communication skills, interpersonal skills, superior customer service, leadership, and organizational skills. Have working knowledge of computers, specifically the Internet, Microsoft Word, Microsoft PowerPoint, Microsoft Access, Microsoft Excel, and Windows.
- License/certification: Current, active, full, and unrestricted License to practice Nursing in accordance with State Board requirements. Nurse applicants must be a current U.S. licensed Registered Nurse.
- License cannot be under investigation nor have any adverse action pending from a Nursing State Board or national licensing/certification agency. All licenses must remain current, valid and unrestricted during contract employment.
- Experience: Six years of clinical nursing experience is required. Intensive Care Unit (ICU), RM and Utilization Management (UM) experience is preferred. Full time employment in a nursing field within the last 48 months is mandatory.
- Work Environment/Physical Requirements: The work can be sedentary. However, there may be some physical demands. Requirements include standing, sitting or bending. Walking may be required throughout the workplace and other Military facilities.
- In compliance with federal law, all persons hired will be required to verify United States Citizenship and to complete the required employment eligibility verification form upon hire.
DUTIES AND RESPONSIBILITIES:
- Monitors team to ensure team members are developing and/or updating the referral Review Tool(s) for assigned product line(s) on an ongoing basis per Product Line guidance and as needed. Ensures team members have access to the most current referral review tools via shared drive or other system as identified by IRMAC RM leadership.
- Serves as advisor and consultant regarding development, implementation, and management of the MTF healthcare referral management activities.
- Under the guidance of RM leadership supports, coordinates, and implements all aspects and stages of the referral management process, identifying patient care process improvements, through continual review and monitoring.
- Independently manages the daily functions of the RM program, ensuring all governing requirements are met. Contributes to the revision of local instructions/review tools/protocols to ensure RM practice is in accordance with policies, dictated from higher authorities.
- Independently and as part of the RM leadership team participates in assessing and evaluating barriers to the implementation process, recommending strategies to effectively overcome and facilitate patient care/referrals.
- Performs RM reviews, makes determinations, and crafts written notifications of all review decisions for internal and external audiences as per Policy/Business Rules and other MHS/IRMAC guidance.
- Performs RM process reviews to identify barriers in review and booking. Crafts written notifications and reports of all reviews and recommendation for improvement, submits them to IRMAC RM Leadership.
- Plans and coordinates new employee in-processing and training. Tracks time, attendance, and performance for team members. Maintains RM leadership aware of findings. Provides training, verbal or written counseling/coaching to contracted team members as necessary.
- Serves as a liaison between MTF providers, civilian network facilities, IRMAC, MCSCs and providers, other health care personnel, and members of UM and referral management services, on matters relating to consultation and referral management processes.
- Consults with Tricare, and other DoD agencies and health plan facilities, as appropriate.
- Prepares all records and reports as may be required in support of services rendered and as required by MTF's Standard Operating Procedures, Federal Law, or Tri-service/DHA Regulations. All written reports/documentation shall be legible and shall be considered property of the government.
- Performs additional duties that support the referral management process under the direction/guidance of IRMAC RM Leadership. Assist with other duties not specified but within scope of and related to RM/ROFR/Healthcare navigation.
- Completes and submits all assigned tasks, projects, reports, etc. accurately within the guidelines established by RM leadership.
- Prepares and reviews RM data reports to help monitor team and individual's productivity and to provide feedback to the appropriate IRMAC leaders as per defined timelines.
- Identifies trends/concerns and report to RM Leadership. Provides feedback to the RM Leadership in daily huddles/team leader meetings/written communication regarding issues/concerns that are related to barriers to the mission.
- Organizes, plans and facilitates team meetings under the direction of the IRMAC RM Leadership.
- Ensures that team members have the tools/information needed to be successful. Assists staff when needed to ensure that the mission is accomplished in a quality/efficient and timely manner.
- Ensures the backup Team Lead is updated on a regular basis, so that he/she can be prepared, when needed. Monitors staff and coverage to ensure IRMAC queues are monitored in the event of planned or unplanned leave requests.
- Review all details of referral for suitability, administrative and clinical completeness, and required tests and pre-work for disposition per IRMAC guidelines. Keeps abreast of facilities’ services, medical treatment capabilities and capacity for Product Lines/Specialties assigned. Proactively collaborates with MCSCs, Product Line Leaders, RM, Appointing Center(s), other members of the healthcare team and MTF points of contact to address any process issues or concerns. Ensures consult processing is done within the established Access to Care guidelines to ensure patients are booked at the right time, with the right provider, at the right place of care. Ensures proper use of the Direct Care System and civilian network resources.
- Reviews referrals within the established guidelines from a market approach utilizing CHCS, AHLTA, HAIMS, Essentris, Managed Care Support Contract Portal and other EHR's or databases when needed. Develops, maintains and updates as needed referral review tools. Collaborates with IRMAC Booking Protocol Liaison, Product Line Leaders, and other points of contact as needed to ensure booking protocols for assigned product lines are up to date.
- Understands, and acts as subject matter expert of the deferral process (when to defer for distance, capacity, capability, second opinion, command directed, continuity of care). Utilizes deferral codes appropriately. Understands access to care standards within the direct care system. Collaborates with manage care support contractor staff when civilian care is warranted.
- Demonstrates ability to verify patients' eligibility in the DEERS and that they are registered in CHCS. If patient is not showing as registered in CHCS and/or DEERS eligible, the contact information for DEERS, the Managed Care Contractor for Tricare and the Benefits Counseling Assistance Coordinator is provided.
- Accesses MCSC’s portal to complete referral reviews, address referral reconciliations, assist patients, MTF or IRMAC staff, or other members of the healthcare team.
- Performs accurate data entry and exercises attention to detail.
- Elevates patients’ concerns, more complex clinical cases to Product Line leadership, or RM leadership as appropriate. Collaborates with Product Line leadership, clinic POCs in efforts to optimize direct care resources for the identified high acuity, high-cost cases or care for active duty service members.
- Communicates with ordering providers/clinic team to clarify and/or seek information in efforts to process referrals per the guidelines established. This may also include engaging Product Line leadership or on call specialty clinic staff. Facilitates provider to provider communication for other than routine referrals per the guidelines established.
- Advises patients of their referral status. This may include providing references for benefit counseling assistance and/or patient advocacy. Advises of Line-of-Duty issues as it relates to referral management.
- Teams with RMC staff in providing, assessing, and improving a wide variety of customer service relations. Ensures that RM Coordinators abide by Referral Management and Appointing booking protocols. Assists IRMAC Chief of RM to ensure Health Service Inspection standards are met at the operational level.
- Receives and makes telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. Routinely monitors and processes referral management CHCS queues (Genesis when applicable) to ensure consults are being processed within the established guidelines. Produces, monitors, analyzes and tracks Referral Management and Product Lines’ reports to ensure timely review, areas requiring focus, processes and closes referrals as per Referral Management guidelines, DHA IPM, NCR MD policies and notifies ordering provider accordingly.
- 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 Medical Director, Product Line leaders, and/or RM leadership for all active, reserve and guard referrals not covered under the TRICARE benefit for approval. Verifies eligibility of beneficiaries using DEERS and initiates/coordinates communication between beneficiaries, the MCSC, team members, internal staff and providers, network/outside providers and ancillary health care workers.
- Demonstrates ability to utilize InterQual, Milliman Ambulatory Care Guidelines or other evidence-base guidelines identified by the MHS, DHA to perform medical necessary reviews.
- Reviews and maintains ROFR referrals into CHCS and database within the established guidelines for proper processing in attempts to recapture workload from the network to the MTF. Produces, monitors and tracks reports from databases related to ROFRs or referrals in general.
- Participates in in-services, Product Line meetings, staff and continuing education programs. May be asked to brief/educate customers such as but not limited to MTFs, MCSC, Referral Management and Appointing staff.
- Establishes and maintains good interpersonal relationships with co-workers, families, peers, and other health team members. Submits all concerns through RM leadership. Be able to identify, analyze, and make recommendations to resolve problems and situations regarding referrals.
- Be productive and demonstrate critical thinking skills to be able to perform with minimal supervisory direction. Be able to independently identify, plan, and carry out projects with consideration for the goals and objectives of the IRMAC policies. Recommendations for improvement are based upon analysis of work, data, review of policies/business rules, processes/procedures and application of guidelines.
- Manages and utilizes multiple complex computer systems for appointment scheduling. Provides pre- appointment instructions to patients as well as the details regarding their specialty appointment (i.e. date/time, provider, location, and pre-requisites such as lab, rads, etc.).
- Assists Medicare beneficiaries in coordinating their medical care within the Direct Care System. This includes scheduling appointments, ensuring pre-requisites are completed prior to specialty care appointments.
- Assists Medicare beneficiaries when civilian care is warranted by providing resources to patients to facilitate this process.
- Provides information about External Program Resource Office (EPRO) to requestors outside the NCR requesting care within the NCR.
- Collaborates with the EPRO office or other MTFs as needed to send or receive referrals outside of the NCR.
- Attends and is an active participant in trainings and in-services.
EDUCATION AND SPECIAL REQUIREMENTS:
- The Licensed Registered Nurse shall possess a Baccalaureate of Science in Nursing Program from a school accredited by the National League of Nursing.
Job Type: Full-time
Pay: From $40.00 per hour
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Employee assistance program
- Health insurance
- Paid time off
- Referral program
- Vision insurance
Standard shift:
Supplemental pay types:
Weekly schedule:
Education:
Experience:
- Nursing: 6 years (Required)
- referral management: 4 years (Preferred)
- military health system: 1 year (Preferred)
Ability to Relocate:
- Bethesda, MD 20816: Relocate before starting work (Required)
Work Location: Hybrid remote in Bethesda, MD 20816