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Nurse Utilization Manager (UM)
Place of Performance: Misawa AB, Japan

General Description:

Nurse Utilization Manager (UM) role is to ensure that health care services are administered with quality, cost efficiency, and within compliance. Provide Utilization Management activities and functions by using Medical Treatment Facility (MTF)-specific Quality Improvement processes to identify areas for review from data, suspected problem areas, and input from departments/services within the facility. Prioritize projects based on high dollar, high volume or problem prone diagnoses. Identify gaps between desired and actual program outcomes and developing an action plan to fix gaps. Determine effectiveness of the plan and continually evaluating the impact of implementation. Incorporate applicable utilization review tasks to ensure patients receive the right care, at the right time, in the right place, with the right provider, at the right cost. Collaborate with staff, facility departments, and outside agencies to determine the best, most cost-efficient care. Provide clinical and administrative oversight over Referral Management Center (RMC) staff, programs and processes.

Specific Tasks:

Prepare all medical documentation to meet or exceed the standards required under applicable Air Force Instructions and the Joint Commission (TJC) guidelines.
Walk throughout facility to interact with staff and providers including transport of relevant documents.
Comply with DoD communication and information technology security standards and policies.
Utilize MTF performance improvement tools in data collection and identifies barriers to the achievement of improvement in multidisciplinary treatment teams and/or clinical programs. You shall seek assistance from the MTFs Quality/Performance Improvement Manager and other case managers as needed.
Comply with requirements and assist clinical programs and treatment teams in preparation for The Joint Commission (TJC), National Committee for Quality Assurance accreditations; the Air Force Inspection Agency Health Service Inspection; Air Force Audit Agency audits and other internal or external reviews, as applicable. You shall implement and monitor follow-up recommendations for corrective actions.
Comply with Air Force Equal Opportunity and safety policies and procedures.
Shall work in collaboration with PCMH teams, case managers (CM), disease management (DM) nurses, special needs coordinator (SNC), health care integrator (HCI) and group practice manager (GPM) to determine measures to target and manage enrollees and/or processes that relate to high-cost, high-volume or problem-prone diagnoses, procedures, services and beneficiaries who have demonstrated high utilization rates. Uses the TRICARE Management Activity Medical Management Guide in performance of these duties. Makes appropriate recommendations to DMs and CMs for high-utilization or high-risk enrollees to be entered into their processes.
Conduct special analyses on patient utilization of health services and health care provider orders and referrals for specialty care, therapies, pharmaceuticals and diagnostic testing to identify both excessive and insufficient use of services Identifies ways to reduce overutilization and suboptimal underutilization of services.
Facilitate utilization management activities by participation in multidisciplinary patient care activities. Initiate/coordinate communication between beneficiaries, PCMH team DoD/civilian providers and ancillary health care workers. Provide feedback regarding utilization review issues within one (1) business day.
Educate PCMH staff on UM role, clinical referral process and tools available to determine appropriate level of care to achieve optimal patient outcomes.
In conjunction with the TRICARE Operations and Patient Administration (TOPA) staff, provides PCMH team with a weekly list of patients admitted to civilian hospitals.
Report any identified quality of care issues to SGH and/or Quality Management officer IAW MTF policy.
Perform medical in-processing utilization reviews for newly in-processed beneficiaries for covered benefits and specific needs and document the review on the patients electronic health record.
Refer complex care findings to CM, DM or SNC.
Track and report medical waiver discrepancies and patient safety issues to the HCI.
Conduct MTF briefing at the installations Right Start program to orient and encourage newly arrived members and dependents on how to utilize MTF services. Work with the GPM, TOPA and Public Health in providing timely and accurate access to care instructions.
Participate in Medical Management, Population Health Working Group (PHWG), AMRO, and care coordination meetings with PCMH teams.
Track, trend and analyze Urgent Care Clinic (UCC) utilization and provide weekly report to PCMH team huddles to ensure follow-up care.
Track, trend and analyze Nurse Advice Line (NAL) utilization patterns; provide recommendations related to conditions, demographic factors, outcomes and formulate process improvements accordingly.
Report trends and metrics to the Executive Committee, Access to Care Working Group and PHWG.
Develop annual Utilization Management plan for inclusion in Population Health/Medical Management Strategic Plan in collaboration with stakeholders.
Provide Referral Management Center (RMC) supervision by:
Reviewing referrals for administrative, clinical completeness and appropriateness in coordination with the Chief, Medical Staff (SGH) or deputy SGH.
Completing medical necessity and benefit reviews on referrals and makes recommendations to the MTF approval authority for approval/disapproval of the specialty care requested. Coordinates with the TRICARE Overseas Program contractor as needed to determine availability of local care.
Submitting referrals from civilian providers to the TRICARE Service Center or TSC for medical necessity and appropriateness review.
Verifying eligibility of beneficiaries using Defense Eligibility Enrollment Reporting System (DEERS).
Reviewing and entering first right of refusal referrals into Composite Health Care System (CHCS) and database within one (1) business day of the date of the referral.

Providing clinical and administrative oversight over RMC personnel by:
Ensuring that RMC staff will coordinate with patient movement office to advise patients of their referral/health treatment options as related to their eligibility per beneficiary status and covered benefits.
Ensuring that RMC staff schedule referral appointments in accordance with Air Force Access to Care (ATC) standards with DoD and civilian health care providers. The UM shall notify the MTF group practice manager, TRICARE Operations and Patient Administration (TOPA) or SGH if ATC standards are not met for referrals.
Ensuring that RMC staff will provide patients with pre-appointment instructions and receive necessary documentation (i.e., diagnostic reports and/or treatment profiles) prior to their referral appointments.
Monitoring referral management CHCS queue to ensure patients who do not utilize the RMC walk-in service are called by RMC staff regarding the status of their referrals. The UM shall provide primary care clinics with patient hand-outs with instructions on RMC services and contact information.
Tracking specialty provider reports and ensuring that RMC personnel forward these to the primary care providers for review. The UM shall provide PCMs with a list of referrals that need close-outs or further review.
Providing training and orientation to new RMC personnel when senior RMC staff are unavailable.
Manning assistance by the UM to the RMC taking more than 7 days or more than 50% of the UMs time shall be requested by the RMC supervisor or TOPA Flight Commander and approved by the SGH.
Representing Medical Management in TOPA meetings and conveying its programs and goals.

Education:

Must possess a Bachelor of Science in Nursing from a college or university accredited by the National League for Nursing Accrediting Commission (NLNAC), or the Commission on Collegiate Nursing Education (CCNE) and recognized by the United States Department of Education.

Licensure:

Must possess a current, valid and unrestricted license as a Registered Nurse in one of the 50 states and/or the District of Columbia, the Commonwealth of Puerto Rico, or territories of the United States.



Experience:

Minimum one year of nursing experience. Experience as a UM or outpatient or ambulatory care nurse is valued.