ABOUT DECYPHER
Decypher is a leading integrator of professional, technology, and management solutions and services. We provide our services globally to Federal, Commercial, Local and State clients. Our employees are our most valuable asset and play an integral role in the success of Decypher and our clients. Working at Decypher is not a job, but a career where your talent and energy is respected, and you can personally make a difference. Decypher invites you to join our professional team. Decypher is an equal opportunity/affirmative action employer committed to diversifying its workforce (M/F/D/V).
DESCRIPTION
Decypher is seeking a Registered Nurse - Utilization Management candidate to support Wright Air Force Base in Dayton, Ohio.
RESPONSIBILITIES
- Assist inpatient discharge planning when needed, as directed. Duties may include
home safety patient/family interview, attending morning planning meeting, and
coordinating transfers, home durable medical equipment and/or home care
services, inpatient rehab, and/or skilled care. - Develop and implement a comprehensive Utilization Management plan/program
in accordance with MTF/AF/DHA goals and objectives. - Perform data/metrics collection on identified program areas; analyzes and trends
results, including over- and underutilization of healthcare resources and
ineffective or inefficient delivery of care. Identifies areas for intensive
management, improved and/or cost containment. Reports utilization patterns,
provides feedback and makes recommendations in a timely manner. - Analyze medical referrals/appointments and general hospital procedures by
monitoring specialty care referrals for appropriateness, covered benefits, and
authorized surgery/medical procedures, laboratory, radiology, and pharmacy. - Evaluate clinical practice patterns and trends and provides SGH and clinical areas with feedback.
- Identify and refer potential cases to Disease Management, Case Management,
Discharge Planning, and the Deployment Availability Working Group. - Participate in Medical Management, Population Health Working Group, and care
coordination meetings as assigned. - Conduct nursing peer review as assigned.
- Educate Patient Centered Medical Home (PCMH) staff on Utilization Management role.
- Assist with PCMH team notification of patients admitted inpatient to civilian
hospitals or civilian emergency department visits. - Performs medical necessity reviews to include concurrent review for length of
stay (LOS) using approved clinical decision tool. Determines medical necessity of
services ordered or rendered. Communicates negative trends to the Chief of the
Medical Staff. - Navigate electronic health record, and TRICARE managed care contractor site.
Acts as referral approval authority for designated referrals MTF/AF/DHA
national guidance and standards. Includes processing and validating durable
medical equipment referrals for PRIME beneficiaries, to include authorization of
SHCP funds for active-duty beneficiaries. Refers all first-level review failures to
SGH or designated POC for further review and disposition. - Verify eligibility of beneficiaries using Defense Eligibility Enrollment Reporting
System (DEERS). Obtains pertinent information from patients/callers and
updates electronic medical record, local referral database, and other office
automation software programs as appropriate and directed. - Other duties as assigned.
QUALIFICATIONS:
Experience
- A minimum of four (4) years’ experience in discharge planning or case
management is required for consideration of a candidate with an associate degree in
nursing. - Two years full-time experience in utilization management is required for
graduates with a Bachelor of Science in Nursing. - Full time employment in a nursing field within the last 36 months is mandatory.
Degree/Education
- Associate Degree (ADN) or a Baccalaureate Degree (BSN) (preferred) program in nursing accredited by a national nursing accrediting agency recognized by the US Department of Education.
Certification
Licensure/Registration
- Must maintain a valid, unrestricted, and current registered nursing license
Must be US citizen.
At Decypher we believe that equal opportunity fuels innovation by using the strengths of individual differences. Therefore, we strive to provide a welcoming and inclusive work environment. Decypher is fully committed to a program of equal opportunity for all applicants and employees and will actively carry out all federal and state regulations and executive orders. We apply our equal opportunity policy to all employment decisions.
This job description is not intended to be all inclusive. Therefore, the employee may be requested to perform other reasonable duties as assigned by the immediate supervisor or other management as required.
