Registered Nurse (Non-Practicing) (Bethesda, MD)

Ivyhill Technologies LLC; Bethesda (MD); On-site; USD 70,000 - 95,000; Full time

Benefits offered by this job

Medical, Dental, Vision

Life and AD&D insurance

Short- and Long-Term Disability

Supplemental Life Insurance

401(k) Plan

Job summary

Ivyhill Technologies LLC in Bethesda, MD is seeking a Registered Nurse (Non-Practicing) to support IRMAC operations within the Defense Health Network. The role involves review of ROFR and referrals, maintaining referral tools, and ensuring RM policy compliance across systems.

This onsite position requires US citizenship, an active RN license, and at least three years of clinical nursing experience. Collaboration with RM leadership and MTF contacts is essential.

Qualifications

• Licensed RN with an active state license and nursing degree.
• Minimum of three years of clinical nursing experience.
• Experience with RM/UM or referral management preferred.
• Proficient in interpreting medical care criteria and guidelines.

Responsibilities

• Review ROFR requests and specialty referrals for completeness and guidance.
• Maintain referral review tools and booking guidance across systems.
• Coordinate with RM leadership, MCSC, and RM centers on referrals.
• Advise patients of referral status and assist with benefit counseling.
• Manage multiple complex computer systems for appointment scheduling.
• Support Medicare beneficiaries within the Direct Care System.

Skills

RN license

Interpersonal skills

Communication skills

Computer literacy

Education

Licensed Registered Nurse (RN) with active license

Tools

MHS-GENESIS

EMR systems

Microsoft Office

Job description

Ivyhill is currently seeking to hire a Registered Nurse (Non-Practicing) to support its contract with the Integrated Referral Management and Appointing Center (IRMAC), the National Capital Regions’ premier coordinating authority for appointing and referral management services for beneficiaries in the Defense Health Network.

Registered Nurse will have overall responsibility for timely review of Right of First Refusal (ROFR) requests, review of Specialty Care Referrals, sustaining up-to-date Specialty Clinic Referral Review tools and booking guidance, complying with Referral and Authorization Business rules, tracking, and resulting of referrals, and full use of Referral Management (RM) information management systems. Will conduct reviews for capacity, capability, medical necessary, deferral to network, and right of first refusal activities.

This is an onsite employment opportunity.

Duties and Responsibilities

1. Review all details of referral for suitability, administrative and clinical completeness, and required tests and pre-work for disposition per IRMAC guidelines. Stay abreast of facilities’ services, medical treatment capabilities and capacity for Product Lines/Specialties assigned. Proactively collaborates with Managed Care Support Contract (MCSC), 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.
2. Review referrals within the established guidelines from a market approach utilizing MHS-GENESIS, MCSC Portal and other EHR's or databases when needed. Develop, maintain and update referral review tools as needed.
3. Understand the deferral process (when to defer for distance, capacity, capability, second opinion, command directed, continuity of care) and utilize deferral codes appropriately.
4. Elevate patients’ concerns, more complex clinical cases to Team Lead, Product Line leadership, or Referral Management (RM) leadership as appropriate.
5. Receive and initiate telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. Routinely monitor and process referral management MHS-GENESIS queues to ensure consults are being processed within the established guidelines.
6. Advise patients of their referral status to include providing references for benefit counseling assistance and/or patient advocacy.
7. Approval authority for all active duty and reserve/guard referrals under the supplemental health care program. Coordinate 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.
8. Review and maintain ROFR referrals into MHS-GENESIS and database within the established guidelines for proper processing in attempts to recapture workload from the network to the MTF.
9. Establish and maintain good interpersonal relationships with co-workers, families, peers, and other health team members. Identify, analyze, and make recommendations to resolve problems and situations regarding referrals.
10. Manage and utilize multiple complex computer systems for appointment scheduling.
11. Assists Medicare beneficiaries in coordinating their medical care within the Direct Care System.
12. Performs additional duties that support the referral management process and the RM Team.

Qualified candidate must be a Licensed Registered Nurse (RN), with an unencumbered active RN license from a State Board of Nursing and graduated from an accredited nursing program.

Must have three (3) years of clinical nursing experience. Referral Management (RM) and Utilization Management (UM) experience is preferred. Full-time employment in a nursing field within the last 24 months is mandatory.

Additionally, the qualified candidate must:

1. Be a U.S. Citizen.
2. Have 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-based guidelines identified by the MHS.
3. Be proficient in the usage and understanding medical terminology, MHS, VA-DOD Sharing Program, TRICARE, HIPAA, release of medical information. Demonstrates ability to manage a high-performing and efficient team.
4. Possess excellent oral and written communication skills, interpersonal skills, superior customer service, leadership, and organizational skills.
5. Have excellent oral and written communication skills, interpersonal skills, superior customer service, leadership, and organizational skills.
6. Have a working knowledge of computers, specifically the Internet, Microsoft Word, Microsoft PowerPoint, Microsoft Access, Microsoft Excel, and Windows.

Ivyhill has a competitive benefits program which includes:

• medical, dental and vision
• Life and AD&D insurance
• Short- and Long-Term Disability
• supplemental Life insurance
• a 401(k) Plan