Registered Nurse- Utilization Management

CentralCare Inc.; San Antonio (TX); On-site; USD 75,000 - 98,000; Full time

Job summary

Central Care Incorporated at Randolph Air Force Base in San Antonio, TX is seeking a Registered Nurse in Utilization Management to support service members, retirees, and families.

You will coordinate patient care with a broad clinical team, ensure compliance with policies, and help implement a comprehensive UM program aligned with the facility’s goals. Join Central Care Incorporated for a meaningful, mission-driven career.

Qualifications

• Bachelor of Science in Nursing required.
• NLNAC or CCNE accreditation required.
• Three years of nursing experience.
• Knowledge of HIPAA and AAAHC standards.

Responsibilities

• Coordinate patient care with a wide array of healthcare professionals.
• Ensure compliance with standards of care and facility policies.
• Direct and supervise care provided 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.
• Performs data/metrics collection and analyzes utilization trends.

Skills

Nursing

Utilization Management

HIPAA

DRGs

Education

BSN

NLNAC/CCNE accreditation

Tools

MHS Genesis

Job description

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.