Registered Nurse (Non-Practicing)
: Job Details :

Zimmerman Associates, Inc. (ZAI) is currently seeking to hire several 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. This is an onsite employment opportunity. However, consideration will be provided for teleworking upon customer's approval. ROLE AND RESPONSIBILITIES: The Registered Nurse (Non-Practicing) has responsibility for RM activities which include timely review of ROFR requests, review of specialty care referrals, sustaining up-to-date Specialty Clinic Referral Review tools and booking guidance, comply with Referral and Authorization Business rules, tracking, and resulting of referrals, and full use of RM information management systems. Individuals will conduct reviews for capacity, capability, medical necessities, deferral to network, and right of first refusal activities.QUALIFICATIONS/SKILLS AND EXPERIENCE:•Licensed Registered Nurse, possessing an unencumbered and active RN license from the State Board of Nursing and graduated from an accredited nursing program. o License cannot be under investigation nor have any adverse action pending from a Nursing State Board or national licensing/certification agency. o All licenses must remain current, valid, and unrestricted during contract employment. o Nurse applicants must be a current U.S. licensed Registered Nurse. •Three years of clinical nursing experience is required. RM and Utilization Management (UM) experience is preferred. •Full time employment in a nursing field within the last 24 months is mandatory. •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. •Proficient in the usage and understanding of medical terminology, MHS, VA-DOD Sharing Program, TRICARE, HIPAA, release of medical information. •Demonstrates ability to manage a high performing and efficient team. •Possess excellent oral and written communication skills, interpersonal skills, superior customer service, leadership, and organizational skills. •Have working knowledge of computers, specifically the Internet, Microsoft Word, Microsoft PowerPoint, Microsoft Access, Microsoft Excel, and Windows.ESSENTIAL TASKS:•Review all details of referral for suitability, administrative and clinical completeness, and required tests and pre-work for disposition per IRMAC guidelines. o Keeps abreast of facilities' services, medical treatment capabilities and capacity for Product Lines/Specialties assigned. o Proactively collaborates with 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. o Ensures Consult processing is completed within the established Access to Care guidelines to ensure patients are booked at the right time, with the right provider, at the right place of care. o Ensures proper use of the Direct Care System and civilian network resources. •Reviews referrals within the established guidelines from a market approach utilizing MHS-GENESIS Managed Care Support Contract Portal and other EHR's or databases as needed. o Develops, maintains and updates as needed, referral review tools. o Collaborates with IRMAC Booking Protocol Liaison, Product Line Leaders, and other points of contact as needed to ensure booking protocols for assigned product lines are up kept up to date. •Understands the deferral process (when to defer for distance, capacity, capability, second opinion, command directed, continuity of care). o Utilizes deferral codes appropriately. o Understands access to care standards within the direct care system. o Collaborates with manage care support contractor staff when civilian care is warranted. •Demonstrates ability to verify patients' eligibility in the DEERS and registration in GENESIS. o If a patient is not showing as registered in MHS-GENESIS and/or DEERS eligible, then the contact information for DEERS, the Managed Care Contractor for Tricare and the Benefits Counseling Assistance Coordinator is provided. •Accesses MCSC's portal to complete referral reviews, address referral reconciliations, assist patients, MTF or IRMAC staff, or other members of the healthcare team. •Reviews 1200-1600 Referrals per month with no more than 5 mistakes for the month. •Elevates patients' concerns, more complex clinical cases to team lead, Product Line leadership, or RM leadership as appropriate. •Collaborates with Product Line leadership, clinic POCs in efforts to optimize direct care resources for the identified high acuity, high-cost cases, or care for active-duty service members. •Communicates with ordering providers/clinic team to clarify and/or seek information in efforts to process referrals per the guidelines established. o This may also include engaging Product Line leadership or On-Call Specialty Clinic Staff. o Facilitates provider to provider communication for other than routine referrals per the guidelines established. •Orients and trains IRMAC staff about the Referral Management review/referral management processes and timeliness. o Serves as advisor to non-clinical staff assigned to his/her team. •Demonstrates ability to provide clinical nursing expertise and referral management guidance to patients, clinical and administrative staff. •Advises patients of their referral status. o This may include providing references for benefit counseling assistance and/or patient advocacy. o Advises of Line-of-Duty issues as it relates to referral management. •Teams with RMC staff in providing, assessing, and improving a wide variety of customer service relations. o Ensures that Referral Management Coordinators abide by Referral Management and Appointing booking protocols. o Assists IRMAC Chief of RM to ensure Health Service Inspection standards are met at the operational level. •Receives and makes telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. o Routinely monitors and processes referral management MHS-GENESIS queues to ensure Consults are being processed within the established guidelines. o Produces, monitors, analyzes, and tracks Referral Management and Product Lines' reports to ensure timely review, areas requiring focus, processes and closes referrals as per Referral Management guidelines, DHA IPM, NCR MD policies and notifies ordering provider accordingly. •Obtains pertinent information from patients/callers and enters data in MHS-GENESIS, AHLTA, MHS GENESIS, Referral database, and other office automation software programs as appropriate. •Acts as an approval authority for all active duty and reserve/guard referrals under the supplemental health care program. o Coordinates 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. o Verifies eligibility of beneficiaries using DEERS and initiates/coordinates communication between beneficiaries, the MCSC, team members, internal staff and providers, network/outside providers, and ancillary health care workers. •Demonstrates ability to utilize InterQual, Milliman Ambulatory Care Guidelines or other evidence-based guidelines identified by the MHS, DHA to perform medical necessary reviews. •Reviews and maintains 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. o Produces, monitors, and tracks reports from databases related to ROFRs or referrals in general. •Participates in in-services, Product Line meetings, staff, and continuing education programs. •Establishes and maintains good interpersonal relationships with co-workers, families, peers, and other health team members. o Submits all concerns through Team Lead/RM leadership. Be able to identify, analyze, and make recommendations to resolve problems and situations regarding referrals. •Be productive and able to independently identify, plan, and conduct projects with consideration for the goals and objectives of the IRMAC policies. o Submit recommendations for improvement are based upon analysis of work, data, review of policies/business rules, processes/procedures, and application of guidelines. •Performs additional duties that support the referral management process. o Assist with other duties not specified but within scope of and related to RM/ROFR/Healthcare navigation. •Manages and utilizes multiple complex computer systems for appointment scheduling. o Provides pre- appointment instructions to patients as well as the details regarding their specialty appointment (i.e., date/time, provider, location, and pre-requisites such as lab, rads, etc.). •On occasion can take on Call Center Team Lead responsibilities. •Assists Medicare beneficiaries in coordinating their medical care within the Direct Care System. o This includes scheduling appointments, ensuring pre-requisites are completed prior to specialty care appointments. •Assists Medicare beneficiaries when civilian care is warranted by providing resources to patients to facilitate this process. •Provides information about EPRO to requestors outside the NCR requesting care within the NCR. •Collaborates with the EPRO office or other MTFs as needed to send or receive referrals outside of the NCR. ZAI is an equal opportunity employer. In compliance with Federal and State Equal Opportunity Laws, qualified applicants are considered for all positions applied for without regard to race, color, religion, sex (including pregnancy and gender identity), national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, veteran status or any other legally protected status. #INDSPN