Registered Nurse - Referral Management

Registered Nurse - Referral Management

Join Decypher and make a direct impact on the health and readiness of America's service members, veterans, and their families. Since 2008 Decypher has offered healthcare industry professionals careers where their expertise is valued, and their work makes a meaningful impact. Decypher partners with the Defense Health Agency to deliver professional services, technology, and management solutions. Our mission is to provide and support quality care for our veterans, servicemembers and their families, across the United States.

Job Summary: Registered Nurse - Referral Management manages and coordinates patient referral processes to ensure timely scheduling, eligibility verification, and compliance with Air Force Access to Care standards, while maintaining accurate documentation and communication across providers and systems. Reviews, authorizes, and tracks referrals and medical services, collaborates with internal and external stakeholders, and supports patients with clear guidance, customer service

Required Qualifications:

• Education: Graduation from an accredited school of nursing acceptable to the Surgeon General, HQ USAF is mandatory.
• Certifications: Basic Life Support (BLS)
• License: Current, active, full, and unrestricted license to practice nursing in accordance with State Board requirements. Nurse applicants shall a current U.S. Registered Nurse.
• Experience:
  • 3 years of direct patient care in a clinical setting
  • 2 years of consecutive utilization management, utilization review or case management experience

U.S. Citizenship is required

Key Responsibilities:

• Schedules referral appointments in accordance with Air Force Access to Care Standards within the direct care system or outside the MTF with network/non-network providers. Ensures appointing is done within the Access to Care standards for 90% of all referrals.
• Attends or briefs the Executive Committee on referral metrics, as necessary.
• Reviews referrals for administrative, clinical completeness and appropriateness. Validates requested medical service, and authorizes surgery/medical procedures, laboratory, radiology, pharmacy, and general hospital procedures and regulations. Collaborates with TRICARE Regional Office Clinical Liaison Nurse and MTF Liaison to address any process issues or concerns.
• Verifies eligibility of beneficiaries using Defense Eligibility Enrollment Reporting System (DEERS).
• Verifies that referrals are processed within the referral priority standards as outlined in the latest AFMRMC Business Rules (Routine, Emergent, and Urgent).
• Tracks referral reports after appointments are kept. Ensures that results from other MTFs and from network/non-network providers are returned to the referring provider and to the medical record within required timelines and follow up with as necessary. Documents that paper referral results are properly filed in patient's health record.
• The MTF will accept/decline urgent priority ROFRs received within 90 minutes of receipt or as updated in TOM 8.5. The MTF will accept/decline routine priority ROFRs received within two business days of receipt or as updated in TOM 8.5. Failure to respond to ROFR requests within the prescribed time is an implied MTF declination and the MCSC will send the patient to the network.
• The RMC will initiate efforts to obtain the CLR as soon as a claim is discovered, upon request by the referring provider or no later than 60 days from the date the referral was ordered, whichever occurs first.
• Imports/scans CLRs into the patients' medical record within three (3) business days from receipt of results from the consulted provider/specialist.
• Provides the correct referral naming convention in T-Cons, clinical notes and HAIMs, or additional systems, as outlined in the latest AFMS RMC business rules.
• Locates referral requests and ensures appropriate documents are available prior to all specialty appointments. Prints diagnostic reports and/or treatment profiles as necessary.
• Completes referral tracking data reports/metrics, as determined by the latest AFMS RM Business rules, local MTF policies.
• Provides positive, courteous, and professional customer service support.
• Manages currency of qualifying factors (e.g. health, security, BLS, initial/annual training requirements, license verifications).
• Coordinates with specialty referral clinics (internal or external) to obtain special patient instructions and/or tests required prior to appointment. Provides pre-appointment instructions to patients as well as the details regarding their referral appointment (i.e., date/time, provider, and location). Ensures patients receive necessary documentation appropriate for the referred medical care visit.
• Facilitates referral activities by participation in multidisciplinary team activities. Initiates/coordinates communication between beneficiaries, team members, internal staff and providers, network/outside providers and ancillary health care workers. Provides timely, descriptive feedback regarding utilization review issues.
• Interfaces with the Managed Care Support HCW (MCSC) and multidisciplinary personnel as needed to ensure appropriateness of referrals. Submits referrals to non-network providers to TRICARE Service Center (TSC) for medical necessity/appropriateness review.
• Performs data collection and review to identify areas requiring intensive management. Refers to case management officials if needed.
• Receives and makes patient telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. Routinely monitors referral management MHS GENESIS queue to ensure patients are being called that do not utilize the RMC walk-in service.
• Contacts patients in event referral requests are invalid, disapproved by second level review/MCSC and reschedules patients as soon as possible or instructs patients of other health care options.
• Receives and appropriately forwards clinical phone consult requests from patients.
• Advises patients of what their referral/health treatment options are as related to their eligibility per beneficiary status and covered benefits. This includes eligibility for travel benefits.
• Notifies the referring provider of all routine priority referrals not used or activated by their patients IAW local MTF policy, but no less than monthly.
• Obtains pertinent information from patients/callers, referrals, physicians or other officials. Enters data in MHS GENESIS, Referral database, and other office automation software programs as appropriate.
• Trains providers/clinical staff during orientation/in-processing and on a recurring basis as needed on the following: roles and responsibilities for ordering referrals/consults; specialty capability within the MTF/eMSM; non-covered benefits to avoid writing referrals that will be denied; use of network specialists; and avoidance of MTF directed referrals and use of non-network specialists without written clinical justification.
• Interfaces with the Managed Care Support HCW (MCSC) and multidisciplinary personnel as needed to ensure appropriateness of referrals. Submits referrals to non-network providers to TRICARE Service Center (TSC) for medical necessity/appropriateness review.
• Performs data collection and review to identify areas requiring intensive management. Refers to case management officials if needed.
• Receives and makes patient telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. Routinely monitors referral management MHS GENESIS queue to ensure patients are being called that do not utilize the RMC walk-in service.
• Contacts patients in event referral requests are invalid, disapproved by second level review/MCSC and reschedules patients as soon as possible or instructs patients of other health care options.
• Receives and appropriately forwards clinical phone consult requests from patients.
• Advises patients of what their referral/health treatment options are as related to their eligibility per beneficiary status and covered benefits. This includes eligibility for travel benefits.
• Notifies the referring provider of all routine priority referrals not used or activated by their patients IAW local MTF policy.

Work Environment & Schedule: Onsite, Monday to Friday, 6:00 am to 6:00 pm with a one (30) thirty minute to 1 hour non billable lunch period. Shifts shall be 8 to 10 hours in length with 30 minutes to 1 hour for lunch, not to exceed 40 per hours week. Overtime is not authorized.

Compensation & Benefits: Up to $50.00 per hour

Decypher is an equal opportunity and affirmative action employer committed to a diverse and inclusive workforce (M/F/D/V)