SUMMARY

Responsible for assuring the receipt of high quality, cost efficient medical outcomes for those enrollees identified as having the need for inpatient/outpatient precertification.

ESSENTIAL DUTIES & RESPONSIBILITIES

• Review precertification requests for medical necessity, referring to the Medical Director those that require additional expertise.
• Review clinical information for concurrent reviews.
• As part of the UMRN program, conduct ongoing availability, monitoring and oversight of non-clinical staff activities.
• Establish effective rapport with other employees, professional support service staff, customers, clients, patients, families, and physicians.
• Employ effective use of knowledge, critical thinking, and skills to:
  • Advocate quality care and enhanced quality of life.
  • Prevent patient complications during hospital stay.
  • Advocate decreased hospital stay when appropriate.
• Maintain accurate records of all patient related interactions.
• Maintain regular and punctual attendance.
• Perform other duties as assigned.

SUPERVISORY RESPONSIBILITIES

None.

MINIMUM QUALIFICATIONS

• Bachelor of Science in Nursing (BSN) is required.
• Minimum of two (2) years of prior experience in Utilization Management.
• Must possess a current, active, full, and unrestricted Registered Nurses (RN) licensed in Colorado, be able to practice using a nurse compact state license or have a license from any United States jurisdiction (with no limitations, stipulations or pending adverse actions).
• Knowledge of medical privacy and confidentiality (Health Insurance Portability and Accountability Act [HIPAA]), and accreditation standards of Accreditation Association for Ambulatory Health Care (AAAHC), The Joint Commission (TJC), and Clinical Practice Guidelines (CPGs).
• Must have knowledge and experience, or demonstrate comprehension during training, with software and databases currently employed at the MTF (e.g., Microsoft Office, Access, Excel, and PowerPoint; Composite Health Care System [CHCS], Armed Forces Health Longitudinal Technological Application [AHLTA]).
• Must have a working knowledge of Ambulatory Procedure Grouping (APGs), Diagnostic Related Grouping (DRGs), International Classification of Diseases-Current Version (ICD), and Current Procedural Terminology- Current Version (CPT) coding; and McKesson (InterQual) and/or Milliman Care Guidelines.
• Must have and maintain current certification in Basic Life Support (BLS) from the American Red Cross. This certificate must be current at all times.
• Must obtain and maintain the site's required health screening and immunization requirements.
• Must obtain and maintain all required documents, certifications, licenses, etc. listed on the credentialling checklist, sent by Katmai’s Credentialing Specialist, for this position for initial hire.
• Must obtain and maintain any necessary security access and/or background checks.

WORK SCHEDULE

Full-time. May be required to work additional hours as needed to complete assignment or project.

TRAVEL

All Market contractors are subject to working at a duty location at any of the MTFs or associated sub clinics within the Colorado Military Health System (CMHS).

DRIVING REQUIREMENTS

None.

PHYSICAL DEMANDS

Position consists of seeing up close and sitting for long periods of time, bending, stooping, crouching, and lifting up to 20 pounds. Frequently uses hands/fingers for manipulation of keyboard and mouse. It is Katmai’s business philosophy and practice to provide reasonable accommodations, according to applicable state and federal laws, to all qualified individuals with physical or mental disabilities.

WORK ENVIRONMENT

Work is performed primarily indoors at a well-lit military treatment facility such as a clinic, outpatient facility or hospital. The environment is normally air conditioned, but conditions may change dependent upon circumstances. Work may need to be performed in a fast-paced environment requiring quick thinking and rapid judgements. Employee will be exposed to a wide variety of clients in differing functions, personalities, and abilities. Exposure to bloodborne pathogens and bodily fluids, latex, radiation or other contaminants and safety issues. May be exposed to infection or diseases from contact with patients. Work is highly social with patients and can be stressful with a high emotional element. Decisions made may substantially impact patients and their families.

COMPENSATION & BENEFITS PACKAGE

• Pay is: $34.33 to $38.90 per hour.
• Eligible Benefits: Medical, Dental, Vision, Group Term Life & AD&D Insurance, Voluntary Life and AD&D Insurances, Voluntary Long-Term & Short-Term Disability Insurance, Dependent Spouse Life Insurance and Dependent Life Insurance, Prescription Drug Coverage, Hearing Coverage, 401(k) Savings Plan, Employee Assistance Program (EAP), Vacation & Paid Personal Time, 11 Paid Federal Holidays, and Leave of Absence.

Compliance:

To be considered for this position, all applicants must apply on the company website,  https://katmaicorp.com/life-at-katmai/

We are a VEVRAA Federal Contractor

We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity or national origin, disability status, protected veteran status, marital status, familial status or any other characteristic protected by law. https://katmaicorp.com/life-at-katmai/#equal_opportunity Preference will be given to Ouzinkie Shareholders, Descendants of Shareholders and Spouses of Shareholders in accordance with Title 43 U.S. Code 1626(g) and Title 42 U.S. Code 2000e - 2(i).

Executive Order 11246, as amended, protects applicants and employees from discrimination based on inquiring about, disclosing, or discussing their compensation or the compensation of other applicants or employees.