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Utilization Manager (RN)

Responsibilities:

ABOUT AVOSYS

Avosys is a growing integrator of professional, technological and management solutions services. Founded in 1998, Avosys provides services nationwide to Federal, Commercial, Local and State clients. We recognize the foundation of our firm is our people and we continue to rise above our competition by hiring the best.

DESCRIPTION

Avosys is seeking a Utilization Manager (RN) to provide services to the military and their families at the Malmstrom AFB, KS.

RESPONSIBILITIES

  • Provide Utilization Management activities include timely processing of Right of First Refusal (ROFR)
  • Screening of specialty care Referrals
  • Sustaining up-to-date Specialty Clinic Booking Guidance
  • MTF Capabilities and ROFR Reports
  • Maintaining up-to-date MTF/Managed Care Support Contract (MCSC) Memorandums of Understanding (MOUs)
  • Comply with Referral and Authorization Business rules, tracking, accounting, and resulting of referrals
  • Conduct reviews for medical necessity, pre-authorization, medical appeals, collection and recovery from insurance carriers, and right of refusal activities
  • Work with the executive staff of clinical operations, resource management, medical records, patient administration, and the quality division within the MTF to provide the appropriate level of resources and minimize cost for beneficiaries

QUALIFICATIONS

  • Knowledge, skills and computer literacy to interpret and apply medical care criteria, such as InterQual or Milliman Ambulatory Care Guidelines
  • Must possess experience in performing prospective, concurrent, and retrospective reviews to justify medical necessity for medical care to aid in collection and recovery from multiple insurance carriers. Review process includes Direct Care and Purchase Care System referrals, ward rounds for clinical data collection, contacting providers to inform them of dollars lost for missing documentation, and providing documentation for appeals resolution
  • Must have a working knowledge of Ambulatory Procedure Grouping (APGs), Diagnostic Related Grouping (DRGs), International Classification of Diseases-Version 9 (ICD), and Current Procedural Terminology-Version 4 (CPT-4) coding
  • Possess excellent oral and written communication skills, interpersonal skills, and have working knowledge of computers, specifically the Internet, Microsoft Word, Microsoft Access, Microsoft Excel, and Windows
  • Baccalaureate of Science in Nursing Program from an approved National League of Nursing
  • Must have current, active, full, and unrestricted License to practiceNursing 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
  • Six years of clinical nursing experience is required with one year of previous experience in Utilization Management is required
  • Full time employment in a nursing field within the last 36 months is mandatory
  • Equivalent combinations of education and experience may be qualifying if approved by the requesting location and the Contracting Officer

Position is contingent upon award of contract

Reference Code:
MSS. MT. UM. 1812
Position Type:
Full Time
Location:
Malmstrom AFB, MT
Industry:
Government Contracting
Shift:
Day Business Hours
Travel:
No
Salary:
Based on Experience
Telework:
No

Equal Opportunity Employer/Veterans/Disabled

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability. If you are an individual with a disability and require a reasonable accommodation to complete any part of the application process, or are limited in the ability or unable to access or use this online application process and need an alternative method for applying, you may contact (210) 888-0775 orJobs@Avosys. comfor assistance.

Avosys
https://avosys. applicantpro. com


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