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Registered Nurse - Utilization Management

Random-e Network, LLC
Fort Carson, Colorado, United States
Highly Competitive
April 04, 2017

Posted By Premium Recruiter


Random-e Network, LLC specializes in management consulting, program management, enterprise solutions, public health infrastructure, and administrative support services. Our mission is to deliver innovative, efficient, and cost effective solutions to industry and federal government agencies. Currently, we are seeking Utilization Manager – Registered Nurse for our government client located in Fort Carson, CO.

Duties and Responsibilities:

Provide a comprehensive UM/Case/Care Management program for all TRICARE eligible beneficiaries. Evaluate discharge planning and case management activities using objective criteria and conducts on-going monitoring and evaluation of the UM program using objective criteria. Organize and collect data using a variety of reports.

The Utilization Manager – RN shall:

• Provide Medicare beneficiaries with information on the “TRICARE for Life” program by phone or in person when TRICARE Service center staff is not available.

• Conduct concurrent reviews of inpatient and outpatient charts daily utilizing pre-established criteria as guidelines to make determinations with regard to medical necessity and appropriateness of care rendered. Trend timeliness of service rendered to support and expeditious hospitalization, monitor appropriate of tests, consults/referrals, procedures, surgeries and medical management of patients to ensure efficient and effective allocation of medical non-medical management of patients to ensure efficient allocation of medical and non-medical resources such as lab tests, x-rays, specialty consults and out of hospital referrals, etc.

• Perform pre-authorization views using InterQual (or alternative method) criteria to determine medical appropriateness prior to services being rendered.

• Identify cases in which quality of care issues were determined questionable or the provider cannot substantiate medical necessity for services. For those cases in which care received was outside the standard of the Chief of the Medical Staff for review.

• Identify trends and sentinel events. Report those trends and observes changes due to findings and recurrence of events.

• Assist medical and nursing staff and clinical case managers with the development and implementation of case/care management for high-risk population. Trend and analyze case/care management data to ensure quality and cost effective case is provided. Oversee patient education processes to ensure adequate understanding of diagnosis and prevention of complication to promote appropriate post hospital resource utilization and decrease incidence of readmission.

• Coordinate discharge planning activities with other case managers and internal/external health members to avoid overlap, duplication, or gaps in recommended treatment modalities. Serve as liaison for Managed Care Support Contractor and Lead Agent case managers and utilization managers.

• Travel, available and must make own transportation for local travel, and must have transportation to complete tasks.

• Working knowledge of the latest versions of office automation software utilized in their area of expertise required, working knowledge of Composite Health Computer System (CHCS) desirable.

• Other duties as assigned.


Certification by a Utilization Management – specific program such as Certified Professional in Healthcare Management (CPHM) is desired.

License: Current licensure to practice in nursing in Colorado. Must maintain an active license or authorizing document from the state in which you are practicing at no expense to the government. Copies of license shall be furnished.

Experience: One year experience in Utilization Management and 5 years of clinical experience in nursing.


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