SUMMARY

Provide consultation and administrative support for TRICARE beneficiaries. Ensure patient flow is optimized by assisting patients (CMHS Referral Management Team including the Central Referral Center- CRC and MTF Referral Management Centers) in processing referrals to specialty care.

ESSENTIAL DUTIES & RESPONSIBILITIES

• Perform data collection and review to identify areas requiring intensive management.
• Coordinate specialty care referrals. Review specialty care referrals for appropriateness and completeness and route the referral to the appropriate place of care.
• Analyze data collected and prepare reports describing resource utilization patterns. Disseminate information to government members of collaborative teams and multidisciplinary hospital committees.
• Serve as functional expert in the area of health benefits and provide health benefits advice to patients.
• Maintain and track referral records.
• Participate with referral centers in providing, assessing, and improving a wide variety of customer services and relations.
• Assist in the management of all forms of communication between beneficiaries, referral centers, internal staff and providers, network/outside providers and ancillary healthcare workers.
• Plan and perform specialty referral reviews IAW established guidelines to provide quality cost-effective care.
• Conduct first level reviews for all referrals to specialty care.
• Act as a facilitator of professional and patient care activities.
• Interface with the Managed Care Support Contractor (MCSC) and multidisciplinary personnel as needed to ensure appropriateness of referrals.
• Identify cases that may benefit from alternative levels of care and involve the case manager as needed to provide direction in care management.
• Plan and prioritize utilization review  (UR)  activities to ensure identified patient needs are addressed promptly.
• Effectively utilize information systems to develop, design, analyze, update and record data.
• Facilitate the development and integration of utilization management (UM) review policies and procedures into operations.
• Perform Right of First Refusal (ROFR) coordination of specialty care referrals.
• Maintain regular and punctual attendance.
• Perform other duties as assigned.

SUPERVISORY RESPONSIBILITIES

None.

MINIMUM QUALIFICATIONS

• Graduation from a State Board of Nursing approved LPN/LVN training program or completion of equivalent military training that permits sitting for the State licensure examination.
• One (1) year of experience within the last two (2) years as a practical or vocational nurse.
• Current, full, active, and unrestricted license as a practical or vocational nurse.
• Basic Life support certification (BLS) course completed by the American Heart Association or American Red Cross.
• Must understand the principles of UR and UM and be able to apply knowledge in processing specialty referrals.
• ROFR knowledge in the area of health benefits.
• Proficient in the current versions of office automation software relevant to the role.
• Working knowledge of EHR Genesis and MCSC databases is required.
• Must have working knowledge of computers, specifically the Internet, Microsoft Word, Microsoft Access, Microsoft Excel and Windows
• Must be able to read, understand, speak, and write English well enough to communicate effectively.
• Must obtain and maintain any necessary security access and/or background checks.

DESIRED QUALIFICATIONS & SKILLS

• Knowledgeable in general medical ethics and health records administration.
• Excellent communications and customer service skills.

WORK SCHEDULE

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

TRAVEL

None.

DRIVING REQUIREMENTS

None.

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 judgments. 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. 

PHYSICAL DEMANDS

Position consists of sitting for long periods of time, using hands/fingers, handling, reaching with hands and arms, speaking or translating.  Periods of walking, standing, bending, kneeling, stooping, crouching, and lifting boxes weighing up to 30 pounds.  Moderate to extended periods of office work with heavy periods of computer usage. May be assigned occasional to moderate periods of analytical tasks requiring extensive reasoning. 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.

COMPENSATION & BENEFITS PACKAGE

• Pay: $28.55/hr
• H&W: $5.09
• Eligible Benefits: Medical, Dental, Vision, Life & AD&D Insurance, Long-Term & Short-Term Disability Insurance, 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).