TM3 Solutions, Inc

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-base guidelines identified by the MHS.. Under the direction and guidance of product line nurse identifies required tests, labs, radiology studies and other pre-requisites specific to each assigned specialty/product line prior to dispositioning using CHCS, AHLTA, HAIMS, Essentris, Humana Government portal, and other electronic health records or databases.. Demonstrates proficiency in utilizing CHCS, AHLTA, ESSENTRIS, CCS/CareRadius (RMS), MCSC’s portal, MHS GENESIS, and AVAYA systems.. Documents in CHCS, explains appropriate options to patients when they refuse appointments within access to care (i.e. point of service, Tricare Select, be connected to Beneficiary Counselor and Assistance Coordinator),. Enters data in CHCS, AHLTA, MHS GENESIS, Referral database, and other office automation software

licensed practical nurse

ROLE AND RESPONSIBILITIES This Licensed Practical Nurse/Referral Management Coordinator Team Lead serves as a subject matter expert on RM. Assists team members with resolution of problems. Recommends new ways to improve the Referral Management process. Implements approved methods and identifies ways to improve job efficiency and make appropriate suggestions to improve processes. Team lead assists RM Leadership in providing oversight of the referral management department as it relates to referral management, care coordination, and referral review. Team lead assists RM leadership in overseeing the referral management activities of the IRMAC. QUALIFICATIONS MANDATORY KNOWLEDGE AND SKILLS: • 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-base guidelines identified by the MHS. • The Contractor must have a working knowledge of medical terminology, MHS, VA-DOD Sharing Program, TRICARE, HIPAA, release of medical information. Demonstrates ability to manage a high-performing and efficient team. • 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. • 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 Practical Nurse. If non-licensed must meet experience qualifications. • License cannot be under investigation nor have any adverse action pending from a Nursing State Board or national licensing/certification agency. • Experience. 6 years of clinical nursing experience is required within the last 48 months in a MHS clinic and/or referral management center. If non-licensed must have a minimum of 6 years’ experience within the last 48 months, which demonstrates the ability to perform the duties of the position working in a MHS referral management center or clinic. • 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 or MHS clinic experience. • Work Environment/Physical Requirements. The work can be sedentary. However, there may be some physical demands. Requirements include standing, sitting or bending. Individual will be required to walk throughout the workplace and other military facilities. DUTIES AND RESPONSIBILITIES: • Performs as team lead to coordinate the implementation process for receiving and processing all Referral/ ROFR requests. Coordinates and monitors workload and assignments, training, and ensures adherence to all policies, procedures and protocols. Monitors IRMAC queues, Referral Management Suite, and ROFR Managed Care Support Dashboard to ensure the referrals are being processed within the guidelines established. • Identifies and address the issues/challenges when consults are not being processed within the established timeframes. Discusses findings and prosed recommendation for process improvement with RM Leadership. • Develops and implements plan to address the issues/challenges and update RM Chief on the progress and improvement. • Tracks time, attendance, and performance for team members. Maintains RM leadership aware of findings. Provides training, verbal or written counseling/coaching to contracted team members as necessary. • Monitors staff and coverage to ensure IRMAC queues are monitored in the event of planned or unplanned leave requests. • Ensures Referral Management Voicemail line is monitored throughout the day and calls are being returned within the guidelines established. Develops and implements plan to address issues/challenges. Monitors voicemail logs to ensure calls are being returned within the guidelines established. • Ensures all consults are transmitted to MCSC within the guidelines established via the Referral Management Suite (RMS) or manual fax (if RMS is down). Audits consults to ensure information being transmitted is accurate and complete. • Listens to wave files when complaints arise and discuss findings and propose improvement plan to RM Leadership. Provides training, verbal or written counseling/coaching to contracted team members as necessary. • Collaborates with RM Leadership in developing and implements RM briefings, trainings for newly hired staff. Provides training and facilitates team meetings as needed. • Collects, reviews, and analyzes data to prepare reports. • Performs referral review duties under the direction/guidance of the product line nurse(s), IRMAC RM Leadership. Reviews all referrals for administrative, clinical completeness and appropriateness. Collaborates with appointing center, case managers, product line nurses, providers, clinics, manage care support contractor liaison and other members of the healthcare team as needed to ensure proper use of Direct Care system and civilian network resources, as well as, ensure that patients are booked at the right time, with the right provider, at the right place of care. • Under the direction and guidance of product line nurse identifies required tests, labs, radiology studies and other pre-requisites specific to each assigned specialty/product line prior to dispositioning using CHCS, AHLTA, HAIMS, Essentris, Humana Government portal, and other electronic health records or databases. Consult and collaborate with assigned product line nurse for clinical guidance as needed or instructed. • Coordinates and facilitates process for research and communicate with requesting providers, product line nurses, manage care support contractor, and others to ensure complete medical information is available in order to make informed decisions about a referral matter. • Sends communication to ordering providers when directed by RM leadership or to assist team members who were directed by product line nurse. This includes but is not limited to communication regarding requests for additional medical/clinical information, consult closures, clarification of care requested. • Demonstrates proficiency in utilizing CHCS, AHLTA, ESSENTRIS, CCS/CareRadius (RMS), MCSC’s portal, MHS GENESIS, and AVAYA systems. • Monitors IRMAC queues to ensure the accurate processing of referrals per the guidelines established from the order date or date consult was directed to queues managed by IRMAC. • Accurately enters/processes/tracks/closes the ROFR referrals per the guidelines established. Monitors team performance to ensure guidelines established are being followed. • Receives and enters ROFR referrals in CHCS from the MCSC’s portal for assigned specialties/product lines. Adheres to the defined timelines for response established by MHS, IRMAC standard operating procedures. Identifies and resolves ROFR issues in accordance with NCR Business Rules. Process all ROFR cases in the interest of optimizing care in the MTFs. Reports concerns related to the ROFR referral process to team lead as needed. • Completes and returns all Clear Legible Reports (CLR) to the ordering civilian provider within the required ROFR timelines. Monitors team performance to ensure guidelines established are being followed. Monitor team ROFR logs/reports to ensure data is being recorded accurately and consults are being processed the guideless established. • Documents and updates all ROFR cases in the IRMAC database. Prepares, reviews, consolidates, and reports data to demonstrate understanding of the ROFR Process. Accurate data entry and attention to detail. Review monthly reports on ROFR data with data analysts, and RM leadership. • Educates NCR providers, staff, patients on the ROFR process as needed. • Maintains the MTFs Specialty Capability Table and Course of Action (COA) status for assigned specialty clinics. • Provides recommendations and/or assistance to staff, patients, and other members of the healthcare team when providing guidance in regards to access to care options as related to patient eligibility and beneficiary status. • Advises patients of what their referral/health treatment options are as related to their eligibility per beneficiary status and covered benefits. This includes eligibility for travel benefits. • Coordinates with specialty referral clinics (internal or external) to obtain special patient instructions and/or tests required prior to appointment. Provides pre-appointment instructions to patients as well as the details regarding their appointment (i.e., date/time, provider, and location). Ensures patients receive necessary documentation appropriate for the referred medical care visit. • Verifies patients' eligibility and that they are registered in CHCS. Ensures DEERS information is up to date. Update demographic information when needed. When working with ROFR referrals, if patient is not registered, will register patient in CHCS based on DEERS information. • Manages and utilizes multiple complex computer systems for appointment scheduling. Schedules referral appointments in accordance with booking direct care system or outside the MTF with network/non-network providers. Ensures appointing is done within the established guidelines of all referrals. • Documents in CHCS, explains appropriate options to patients when they refuse appointments within access to care (i.e. point of service, Tricare Select, be connected to Beneficiary Counselor and Assistance Coordinator), • Contacts product line nurse/clinic when appropriate for accommodation of high valuable cases. • Interfaces with the MCSC and multidisciplinary personnel as need to ensure appropriateness of referrals. Submits referrals to non-network providers to TRICARE Service Center for medical necessity/appropriateness review. • Performs data collection and review to identify areas requiring intensive management. Refers to case management officials if needed. • Develops and maintains referral management reports. • Receives and makes patient telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. Routinely monitors referral management voicemail to ensure patient calls are returned within the guidelines established. • Receives and appropriately forwards clinical concerns from patients to product line nurse or IRMAC RM Leadership. Refers to case management officials if needed. • 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. • Obtains pertinent information from patients/callers, referrals, physician or other officials. Enters data in CHCS, AHLTA, MHS GENESIS, Referral database, and other office automation software • programs as appropriate. • Assist with other duties within the Referral Management Office related to the processing referrals to Direct Care MTFs and Civilian Care per IRMAC responsibilities. • Provides information about EPRO to requestors outside the NCR requesting care within the NCR. • Assists Medicare beneficiaries in coordinating their medical care within the Direct Care System. This includes scheduling appointments, ensuring pre-requisites are completed prior to specialty care appointments. If civilian care is warranted, navigator will provide notification/communication to Medicare eligible beneficiaries via Medicare packages or other method(s) as directed by IRMAC. • Assists Medicare beneficiaries when civilian care is warranted by providing resources to patients to facilitate this process. • Tracks and closes unused referrals as directed by DHA IPM, NCR MD policies and notifies ordering provider accordingly. • Understands, and act 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. Monitors team to ensure the MCSC receives accurate response to the deferral requests sent back for reconciliation/additional information. Ensures timelines established are being followed. • Performs administrative duties that support the referral management process under the direction/guidance of the product line nurse(s), team lead, and/or IRMAC RM Leadership. Assist with other duties not specified but within scope of and related to RM/ROFR/Healthcare navigation. • Orients and trains new IRMAC staff about the referral processes and timeliness. • Monitors team to ensure team members are developing and/or updating the referral Review Tool(s) for assigned product line(s) on an ongoing basis per Product Line guidance and as needed. Ensures team members have access to the most current referral review tools via shared drive or other system as identified by IRMAC RM leadership. • Completes and submits all assigned tasks, projects, reports, etc. accurately within the guidelines established by RM leadership. EDUCATION: • Proof of License Practical Nurse Certification/Licensure from an approved National League of Nursing program. For non-licensed staff must have a bachelor's degree or a minimum of 6 years’ experience, which demonstrates the ability to perform the duties of the position working in a MHS referral management center or clinic. #J-18808-Ljbffr

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