LPN Utilization Review Nurse Referral Management Review
iCallidus is seeking a LPN Utilization Management Nurse Reviewer (Referral Management Review). This individual will participate in direct, referral management review activities within the Integrated Referral Management and Appointing Center (IRMAC) in Bethesda, MD.
Licensed Practical Nurse dedicated to providing quality, patient-center care in a multi-disciplinary team within the (IRMAC), Integrated Referral Management Appointing Center environment, supporting Tricare and Humana active duty member, dependents, and veterans.
Exceptional ability to observe, examine, identify problems, and take precaution measures to take care of all personnel in a timely manner. Profound organizational and excellent communication skills, customer service skills, fast learner, dedicated and loyal, active duty, veteran, and dependent focused, team oriented, exceptional team-player, self-driven, self-motivated, takes initiative, and time management skills are mandatory requirements.
Must have LPN referral management clinical review, proficiency and ability to turnaround a high volume of referral cases for administrative, clinical completeness, and appropriateness to product line specialty.
Must have familarity and comfortable working in a multi disciplinary clinical team setting of product line nurses and chairs, AHLTA, CHCS, DEERS, HAIMS, military health systems, GENESIS, InterQual, Milliman Utilization Review Guidelines, medical terminology, utilization management, military treatment facilities, case management, Tricare & Humana background, case management, patient triage, patient care coordination.Prior Utilization Review/Management & Utilization Case Management experience is a plus. Past experience proficiently conducting clinical review, handling, and managing a high volume of referral cases thoroughly and accurately is highly preferred.
Incentives:
- Collaborative and supportive work environment.
- Meaningful opportunity to assist military, veterans, and dependents in need of medical care.
- Paid in-person training.
- Comprehensive Benefits Package including medical, vision, dental, 401(K).
- Fringe benefits to help pay for medical, vision, and dental.
- Set day hours (7:30 to 4 pm, Monday through Friday).
- On-site to remote opportunity.
- Competitive pay.
- Interact and learn from product line nurses and chairs in their specialized field.
- Ability to gain hands-on experience with military health system including DEERS and the new groundbreaking system, GENESIS.
- Ability to obtain a Security Clearance upon successful background check.
Main Responsibilities:
- Performs clinical review of referrals under the direction/guidance of the product line nurse(s), IRMAC Referral Management Leadership.
- Reviews all referrals for administrative, clinical completeness, and appropriateness.
- Collaborates with appointing center, case managers, product line nurses, providers, clinics, manage care support contractor liaison and other members of the healthcare team as needed to ensure proper use of Direct Care system and civilian network resources.
- Under the direction and guidance of product line nurse identifies required tests, labs, radiology studies and other pre-requisites specific to each assigned specialty/product line prior to dispositioning using CHCS, AHLTA, HAIMS, Essentris, Humana Government portal, and other electronic health records or databases.
- Consult and collaborate with assigned product line nurse for clinical guidance as needed or instructed.
- Coordinates and facilitates process for research and communicate with requesting providers, product line nurses, manage care support contractor, and others to ensure complete medical information is available in order to make informed decisions about a referral matter.
- Send communication to ordering providers when directed by Referral Management team lead or product line nurse. This includes, but is not limited to communication regarding requests for additional medical/clinical information, consult closures, clarification of care requested.
- Demonstrates proficiency in utilizing Composite Health Care System (CHCS), Armed Forces Health Longitudinal Technology (AHLTA), ESSENTRIS, CCS/CareRadius (RMS), Managed Care Support Contractors portal, MHS GENESIS, and AVAYA systems.
- Accurately processes referrals per the guidelines established from the order date or date consult was directed to queues managed by IRMAC.
- Accurately enters/processes/tracks/closes the Right of First Refusal (ROFR) referrals per the guidelines established.
- Receives and enters ROFR referrals in CHCS from the Managed Care Support Contractors portal for assigned specialties/product lines.
- Assists with other duties not defined but within the scope of and related to referral management process.
- Must be a Licensed Practical Nurse with an active license in good standing.
- Minimum of 2-3 years of clinical review experience as a Licensed Practical Nurse.
- Must have direct LPN referral management experience.
- Must be able to commute and work on-site in Bethesda, MD.
- Candidates within close proximity to Bethesda, MD are highly preferred.
- Ability to conduct a thorough clinical review, process, and submit to the correct product line specialty of nurses and chairs.
- Ability to manage and handle a high volume of referral cases in a fast paced environment.
Preferred Qualifications:
- Military health system (MHS) background including CHCS, AHLTA, DEERS, GENESIS, InterQual, and Milliman Guidelines.
- Excellent communication and writing skills.
- Attention to detail, team player, ability to work independently, highly organized, great time management, and prioritization skills.
- Tech savvy, trainable, and be a fast learner with utilizing and navigating the various, military health systems.
- Previous experience working in a clinical, military, health setting.
Education:
Proof of License Practical Nurse Certification/Licensure from an approved National League of Nursing program.
License/Certification/Security Clearance Requirements:
- Current, active, full, and unrestricted License to practice nursing in accordance with State Board requirements. Nurse applicants must be a current U.S. licensed Practical Nurse. License cannot be under investigation nor have any adverse action pending from a Nursing State Board or national licensing/certification agency.
- Ability to obtain and maintain a Security Clearance is required. An active, Security Clearance is a plus.
Employment Type:
- Monday through Friday, 40 hours, 7:30 to 4 pm
- On-site position in Bethesda, MD.
Compensation:
$28 -$32 per hour
Benefits:
- Medical, Vision, Dental, 401(K), Fringe Benefits, Basic Life Insurance
- Vacation, PTO, Sick Leave will be applicable after the 90-Day Probationary Period.
EEO Statement
iCallidus is an Equal Opportunity/Affirmative Action Employer. We do not unlawfully discriminate on the basis of race, color, religion, age, sex, creed, national origin, ancestry, citizenship status, marital or domestic or civil union status, familial status, affectional or sexual orientation, gender identity or expression, genetics, disability, military eligibility or veteran status, or any other protected status.
Benefits
Benefits:
- Medical, Vision, Dental, 401(K), Fringe Benefits, Basic Life Insurance
- Vacation, PTO, Sick Leave will be applicable after the 90-Day Probationary Period.