Registered Nurse - Utilization Manager

Registered Nurse - Utilization Manager

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: The Registered Nurse - Utilization Manager must have the ability to sit or stand for extended periods while reviewing medical records and working on a computer, with frequent use of standard office equipment and clear verbal and written communication. Must have sufficient visual acuity and attention to detail to analyze complex clinical documentation, with occasional ability to move about the workplace and lift up to 1015 pounds.

Required Qualifications:

• Education: Associate degree (ADN) or Bachelor of Science in Nursing (BSN) from a program accredited by a national nursing accrediting agency recognized by the U.S. Department of Education.
• Certifications: Basic Life Support (BLS)
• License: Valid, Active, Unrestricted Registered Nurse License
• Experience: 4 years of experience if ADN holder; 2 years of experience if BSN holder - in discharge planning or case management. Full-time employment in a nursing field within the last 36 months is required.

U.S. Citizenship is required

Key Responsibilities:

• Assist with inpatient discharge planning as needed, including home safety patient/family interviews, attending morning planning meetings, and coordinating transfers, home durable medical equipment, home care services, inpatient rehabilitation, and skilled care.
• Develop and implement a comprehensive Utilization Management (UM) program aligned with Military Treatment Facility (MTF), Air Force (AF), and Defense Health Agency (DHA) goals and objectives.
• Collect, analyze, and trend data/metrics on program areas to identify over- and underutilization of healthcare resources, inefficiencies, and areas for cost containment. Provide reports, feedback, and recommendations in a timely manner.
• Monitor specialty care referrals, ensuring appropriateness, covered benefits, and authorization for medical procedures, laboratory, radiology, and pharmacy services.
• Evaluate clinical practice patterns and trends, providing feedback to the Chief of Hospital Services (SGH) and clinical teams.
• 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 reviews as assigned.
• Educate Patient-Centered Medical Home (PCMH) staff on the role of Utilization Management.
• Assist the PCMH team in notifying patients admitted to civilian hospitals or civilian emergency departments.
• Perform medical necessity reviews, including concurrent reviews for length of stay (LOS) using approved clinical decision tools. Assess medical necessity of services and communicate negative trends to the Chief of the Medical Staff.
• Navigate electronic health records and TRICARE managed care contractor sites.
• Act as referral approval authority for designated referrals based on MTF/AF/DHA national guidance and standards, including processing and validating durable medical equipment referrals for PRIME beneficiaries and authorizing Supplemental Health Care Program (SHCP) funds for active-duty beneficiaries.
• Refer all first-level review failures to SGH or designated points of contact for further review and disposition.
• Verify beneficiary eligibility using the Defense Eligibility Enrollment Reporting System (DEERS). Obtain pertinent patient information and update electronic medical records, local referral databases, and other office automation systems as needed.
• Perform other duties as assigned.

Work Environment & Schedule: Monday - Friday; 8 hour shifts 7:00am - 16:30 with a 30-minute uncompensated lunch.

Compensation & Benefits: $44.92 per hour + $4.93 H&W IF APPLICABLE

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