Quality Innovation, Inc. Hiring For Referral Management Health Care Coordinator at Bethesda, MD  Full Time

Referral Management Health Care Coordinator
 

The Licensed Practical Nurse/Referral Management Coordinator will provide care coordination and referral management activities in the IRMAC.
 

Qualifications:

1. Knowledge, skills and computer literacy to interpret and apply medical care criteria.
2. A working knowledge of medical terminology and the military health system.
3. Possess excellent oral and written communication skills, interpersonal skills, superior customer service, leadership, and organizational skills. Have working knowledge of computers, specifically the Internet, Microsoft Word, Microsoft PowerPoint, Microsoft Access, Microsoft Excel, and Windows.
4. License/certification. 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.
5. Experience. Six years of clinical nursing experience is required. Intensive Care Unit (ICU), RM and Utilization Management (UM) experience is preferred. Full time employment in a nursing field within the last 48 months is mandatory.
6. Equivalent combinations of education and experience may be qualifying. If education or experience is used to meet the specialized requirements of this position, it must be directly related to referral/utilization management in the Military Health System.
7. Work Environment/Physical Requirements. The work can be sedentary. However, there may be some physical demands. Requirements include standing, sitting or bending. Walking may be required throughout the workplace and other Military facilities.

Responsibilities include:

1. Review all details of referral for suitability, administrative and clinical completeness, and required tests and pre-work for disposition. Keeps abreast of facilities’ services, medical treatment capabilities and capacity for Product Lines/Specialties assigned. Proactively collaborates with other members of the healthcare team and treatment facility points of contact to address any process issues or concerns. Ensures consult processing is done within the established Access to Care guidelines to ensure patients are booked at the right time, with the right provider, at the right place of care. Ensures proper use of the Direct Care System and civilian network resources.
2. Reviews referrals within the established guidelines utilizing facility electronic health record system and databases when needed. Develops, maintains and updates as needed referral review tools. Collaborates with other points of contact as needed to ensure booking protocols for assigned product lines are up to date.
3. Understands, and acts as subject matter expert of the deferral process (when to defer for distance, capacity, capability, second opinion, command directed, continuity of care). Utilizes deferral codes appropriately. Understands access to care standards within the direct care system. Collaborates with manage care support contractor staff when civilian care is warranted.
4. Demonstrates ability to verify patients’ eligibility and registration status. If patient is not showing as registered and/or eligible, provides patient with points of contact and information to facility registration.
5. Utilizes electronic systems to complete referral reviews, address referral reconciliations, assist patients, MTF or other members of the healthcare team.
6. Performs accurate data entry and attention to detail.
7. Elevates patients’ concerns, more complex clinical cases to team lead or other team members as appropriate. Collaborates with other team members in efforts to optimize direct care resources for the identified high acuity, high cost cases or care for active duty service members.
8. Communicates with ordering providers/clinic team to clarify and/or seek information in efforts to process referrals per the guidelines established. This may also include engaging leadership or on call specialty clinic staff. Facilitates provider to provider communication for other than routine referrals per the guidelines established.
9. Assists with orientation and training for new staff about the Referral Management review/referral management processes and timeliness. Serves as advisor to non-clinical staff assigned to his/her team.
10. Demonstrates ability to provide clinical nursing expertise and referral management guidance to patients, clinical and administrative staff.
11. Advises patients of their referral status. This may include providing references for benefit counseling assistance and/or patient advocacy. Advises of Line-of-Duty issues as it relates to referral management.
12. Teams with other team members in providing, assessing, and improving a wide variety of customer service relations. Ensures that Referral Management Coordinators abide established protocols.
13. Receives and makes telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. Routinely monitors and processes referral management from electronic system queues to ensure consults are being processed within the established guidelines. Produces, monitors, analyzes and tracks Referral Management reports to ensure timely review, areas requiring focus, processes and closes referrals and notifies ordering provider accordingly.
14. Be productive and demonstrate critical thinking skills to be able to perform with minimal supervisory direction. Be able to independently identify, plan, and carry out projects with consideration for established goals and objectives. Recommendations for improvement are based upon analysis of work, data, review of policies/business rules, processes/procedures and application of guidelines.

Requirements:

1. Education/Experience – The Licensed Registered Nurse shall possess a Baccalaureate of Science in Nursing Program from a
   school accredited by the National League of Nursing.
2. Credentialing – Must possess a valid, active, unrestricted license in registered nursing.
3. Security – Must be able to pass a national security background check for access into military electronic systems.
4. Must maintain active and valid HIPAA certification.
5. Must be able to operate a personal computer to input, store, retrieve and manipulate data for various reports as required.
6. Must be able to use various software programs to maintain database files and prepare reports, including Microsoft Word, Excel, PowerPoint and Outlook. 

Quality Innovation, Inc. is an Equal Opportunity Employer and as such abides by the requirements of 41 CFR §§ 60-1.4(a), 60-300.5(a) and 60-741.5(a). These regulations prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, gender identity or sexual orientation.