Registered Nurse - Utilization Manager

Decypher

Patterson (OH)

On-site

USD 51,052 - 72,711

Full time

14 days+

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Job summary

A healthcare solutions provider is seeking a Registered Nurse - Utilization Manager in Patterson, Ohio. The role requires a valid nursing license and entails responsibilities such as assisting with patient discharge planning and developing a robust Utilization Management program. Candidates should have relevant experience in case management and a commitment to quality patient care. This position offers a competitive hourly wage along with benefits and a structured work schedule from Monday to Friday.

Qualifications

4 years of experience if ADN holder; 2 years of experience if BSN holder in discharge planning or case management.
Full-time employment in a nursing field within the last 36 months is required.
Valid, Active, Unrestricted Registered Nurse License.

Responsibilities

Assist with inpatient discharge planning.
Develop and implement a comprehensive Utilization Management program.
Monitor specialty care referrals and ensure appropriateness.

Skills

Communication skills

Attention to detail

Analytical skills

Education

Associate degree (ADN) or Bachelor of Science in Nursing (BSN)

Tools

Electronic health records

Job description

Join Decypher and make a direct impact on the health and readiness of America’s service members, veterans, and their families. Since 2008 Decypher has offered healthcare industry professionals careers where their expertise is valued, and their work makes a meaningful impact. Decypher partners with the Defense Health Agency to deliver professional services, technology, and management solutions. Our mission is to provide and support quality care for our veterans, servicemembers and their families, across the United States.

Overview

Job Summary: The Registered Nurse - Utilization Manager must have the ability to sit or stand for extended periods while reviewing medical records and working on a computer, with frequent use of standard office equipment and clear verbal and written communication. Must have sufficient visual acuity and attention to detail to analyze complex clinical documentation, with occasional ability to move about the workplace and lift up to 10–15 pounds.

Qualifications

Education:
- Associate degree (ADN) or
- Bachelor of Science in Nursing (BSN) from a program accredited by a national nursing accrediting agency recognized by the U.S. Department of Education.
Certifications:
- Basic Life Support (BLS)
License: Valid, Active, Unrestricted Registered Nurse License
Experience:
- 4 years of experience if ADN holder; 2 years of experience if BSN holder - in discharge planning or case management.
- Full-time employment in a nursing field within the last 36 months is required.
U.S. Citizenship is required

Key Responsibilities

Assist with inpatient discharge planning as needed, including home safety for patients and families.
Interview, attend morning planning meetings, and coordinate transfers, home durable medical equipment, home care services, inpatient rehabilitation, and skilled care.
Develop and implement a comprehensive Utilization Management (UM) program aligned with Military Treatment Facility (MTF), Air Force (AF), and Defense Health Agency (DHA) goals and objectives.
Collect, analyze, and trend data/metrics on program areas to identify over- and underutilization of healthcare resources, inefficiencies, and areas for cost containment. Provide reports, feedback, and recommendations in a timely manner.
Monitor specialty care referrals, ensuring appropriateness, covered benefits, and authorization for medical procedures, laboratory, radiology, and pharmacy services.
Evaluate clinical practice patterns and trends, providing feedback to the Chief of Hospital Services (SGH) and clinical teams.
Identify and refer potential cases to Disease Management, Case Management, Discharge Planning, and the Deployment Availability Working Group.
Participate in Medical Management, Population Health Working Group, and care coordination meetings as assigned.
Conduct nursing peer reviews as assigned.
Educate Patient-Centered Medical Home (PCMH) staff on the role of Utilization Management.
Assist the PCMH team in notifying patients admitted to civilian hospitals or civilian emergency departments.
Perform medical necessity reviews, including concurrent reviews for length of stay (LOS) using approved clinical decision tools. Assess medical necessity of services and communicate negative trends to the Chief of the Medical Staff.
Navigate electronic health records and TRICARE managed care contractor sites.
Act as referral approval authority for designated referrals based on MTF/AF/DHA national guidance and standards, including processing and validating durable medical equipment referrals for PRIME beneficiaries and authorizing SHCP funds for active-duty beneficiaries.
Refer all first-level review failures to SGH or designated points of contact for further review and disposition.
Verify beneficiary eligibility using the Defense Eligibility Enrollment Reporting System (DEERS). Obtain pertinent patient information and update electronic medical records, local referral databases, and other office automation systems as needed.
Perform other duties as assigned.