RN - Utilization Management

Spectrum Healthcare Resources is excited to offer a potential career opportunity for an Utilization Management Registered Nurse at the Cannon Air Force Base. This civilian position is an outstanding chance to contribute to the health and well-being of our military members while enjoying a rewarding work-life balance and a supportive patient community.

Join us in making a significant impact on the lives of those who serve our country, with a focus on quality care and professional development!

Requirements:

Baccalaureate of Science in Nursing Program from an approved National League of Nursing.
• Current, active, full, and unrestricted License to practice Nursing in accordance with State Board requirements. Nurse applicants must be a current U.S. licensed Registered Nurse.
• License cannot be under investigation nor have any adverse action pending from a Nursing State Board or national licensing/certification agency.
• Six years of clinical nursing experience is required.
• One year of previous experience in Utilization Management is required.
• Full-time employment in a nursing field within the last 36 months is mandatory.
• Equivalent combinations of education and experience may be qualifying if approved by the requesting location and the Contracting Officer. If education or experience is used to meet the specialized requirements of this position, it must be directly related to referral/utilization management.

Job Responsibilities:

• Reviews specialty care referrals for appropriateness, benefits, and authorization. Coordinates with TRICARE and liaison for clarification.
• Assists in orienting and training Medical Management staff. Ensures Health Service Inspection standards are met.
• Handles patient calls and correspondence regarding appointments and referrals. Monitors CHCS queue for patient follow-ups.
• Gathers and inputs patient information into CHCS, AHLTA, MHS GENESIS, and other databases.
• Approves active duty and reserve/guard referrals. Verifies eligibility and coordinates communications.
• Processes first right of refusal referrals within one business day. Updates reports and capability databases.
• Develops and implements a comprehensive plan following the DoD Medical Management Guide.
• Analyzes medical care practices for trends and under/over-utilization. Provides feedback on utilization review issues.
• Collects and analyzes data, preparing reports on resource utilization. Identifies areas for improvement.
• Maintains reports on denied/reduced payments and provider profiles. Liaises with higher headquarters and organizations.
• Ensures daily reconciliation of open referrals. Monitors admissions to civilian hospitals and submits monthly reports.
• Participates in continuing education and in-services. Serves on the Prime Service Area Executive Council.
• Maintains good relationships with team members and addresses concerns through the Utilization Management Director.
• Manages projects independently, developing procedures and guidelines based on observations and reviews.

Company Overview:

At Spectrum, we leverage over thirty-five years of experience to deliver innovative and cost-effective solutions for federal agencies. Certified by the Joint Commission, we are committed to the highest standards of service and reliability. Spectrum Healthcare Resources is proud to be an equal opportunity employer, welcoming applications from all qualified individuals, regardless of race, color, religion, sex, national origin, disability status, protected veteran status, or any other protected characteristic.