Licensed Practical Nurse Referral Reviewer

Zimmerman Associates - Bethesda, MD

Bethesda, MD

Securities, Commodity Contracts, and Other Financial Investments and Related Activities

About the position

Zimmerman Associates, Inc. (ZAI) is currently seeking to hire Licensed Practical Nurse Referral Reviewers to support its contract with the Integrated Referral Management and Appointing Center (IRMAC), the National Capital Regions' premier coordinating authority for appointing and referral management services for beneficiaries in the Defense Health Network. The candidate must be a U.S Citizenship required as well as ability to obtain a Public Trust Clearance. Pay Rate: $31.44 hrly plus $4.93 H&W.

Responsibilities

• Facilitate centralized product line and specialty referrals for Active-Duty Service Members and Tricare Prime beneficiaries enrolled to a Military Treatment Facility (MTF) in the National Capital Region.
• Perform referral review duties, collaborating with team leads, Product Line Leaders, Appointing Center(s) and other members of the healthcare team and MTF points of contact as necessary.
• Review all referrals for administrative, clinical completeness and appropriateness upon receipt, dispositioning the referral within 24 hours from the date referral was written.
• Collaborate with appointing center, case managers, product line nurses, providers, clinics, manage care support contractor liaison and other members of the healthcare team as needed.
• Receive and place telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals.
• Advise patients of their referral status and provide references for benefit counseling assistance and/or patient advocacy.
• Reschedule/instruct patients of other health care options within 3 days of notification of disapproved referral or invalid referral.
• Receive and enter ROFR referrals in MHS-GENESIS from the MCSC's portal for assigned specialties/product lines.
• Complete and return Clear Legible Reports (CLR) to the ordering civilian provider within the required ROFR timelines.
• Verify patients' eligibility in MHS-GENESIS.
• Provide recommendations and/or assistance to staff, patients, and other members of the healthcare team regarding access to care options.
• Document in MHS-GENESIS, explaining appropriate options to patients when they refuse appointments.
• Contact product line nurse/clinic when appropriate for accommodation of highly valuable cases.
• Interface with the MCSC and multidisciplinary personnel as needed to ensure appropriateness of referrals.
• Routinely monitor referral management voicemail to ensure patient calls are returned within the guidelines established.
• Assist Medicare beneficiaries in coordinating their medical care within the Direct Care System.
• Close unused referrals as directed by DHA IPM, NCR MD policies and notify ordering provider accordingly.
• Orient and train new IRMAC staff in the referral processes and timelines.
• Other duties as assigned.

Requirements

• Minimum of an Associate's degree.
• Current, active full and unrestricted License Practical Nurse Certification/Licensure from an approved National League of Nursing program.
• 2 years of clinical nursing experience.
• Knowledge, skills, and computer literacy to interpret and apply medical care criteria, such as InterQual, Milliman Ambulatory Care Guidelines, Specialty Referral Guidelines (SRGs) or other evidence-based guidelines identified by the Military Health System (MHS).
• Knowledge of medical terminology with an ability to learn MHS, VA-DOD Sharing Program, TRICARE, HIPAA, release of medical information.
• Effective communication and people skills.
• Superior customer service skills.
• Demonstrated knowledge and understanding of Access to Care Standards within the Direct Care System.
• Attention to detail and the appropriate use of deferral codes.
• Excellent organizational skills, i.e., ability to manage time effectively, prioritize tasks, set goals, and implement plans for achieving those goals.
• Knowledge of Microsoft Suite of Products, including Word, Excel, PowerPoint, Access, Outlook (email), and the Internet.

Benefits

• $31.44 hrly plus $4.93 H&W