Licensed Practical Nurse Referral Reviewer

Zimmerman Associates, Inc. (ZAI) is currently seeking to hire a Licensed Practical Nurse Referral Reviewer to support a government contract bid in the Bethesda, MD area. This is an onsite employment opportunity. However, consideration will be provided for teleworking upon customer's approval.

ROLE AND RESPONSIBILITIES:

The Licensed Practical Nurse Referral Reviewer has overall responsibility for reviewing the details of referral for appropriateness, administrative and clinical completeness, and complinace with Specialty Referral Guidelines for dispositioning pursuant to the IRMAC guidelines.

QUALIFICATIONS/SKILLS AND EXPERIENCE:

* Associate's degree and 2 years' experience, which demonstrates the ability to perform the duties of the position working in a MHS referral management center or clinic.
* Licensed Practical Nurse Certification/Licensure from an approved National League of Nursing Program.
* LPNs possess an unencumbered and active license to practice nursing in accordance with the State.
* Two years of clinical nursing experience is required.
* 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 MHS.
* Proficient in the usage and understanding of medical terminology, MHS, VA-DOD Sharing Program, TRICARE, HIPAA, release of medical information.
* Have working knowledge of computers, specifically the Internet, Microsoft Word, Microsoft PowerPoint, Microsoft Access, Microsoft Excel, and Windows.

ESSENTIAL TASKS:

* Review all details of referral for appropriateness, administrative and clinical completeness, and Specialty Referral Guideline (SRG) compliance for disposition per IRMAC guidelines.
* Complete the referral review process upon receipt of referral.
* Regularly review facilities' services, medical treatment capabilities and capacity for Product Lines/Specialties assigned.
* Proactively collaborates with Team Leads, Product Line Leaders, Appointing Center(s), other members of the healthcare team and MTF points of contact to address any process issues or concerns.
* Ensures Consult processing is completed 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.

o Ensures proper use of the Direct Care System and civilian network resources.

* Receives and makes telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals.
* Routinely monitors and processes referral management Genesis Work Lists (Genesis when applicable) to ensure Consults are being processed within the established guidelines.
* Initiate, follow, manage, and close all referrals within timeline standards identified by the RMC business rules and other current Government policies, regulations, or memorandums.
* Performs referral review duties, seeking guidance from the product line nurse(s), when necessary.

o 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.

o 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 to make informed decisions about a referral matter.
* Verifies patients' eligibility and ensures patients are registered in MHS-GENESIS.

o If a patient is not showing as registered in MHS Genesis and is eligible for care, then the contact information for DEERS, the Managed Care Contractor for Tricare and the Benefits Counseling Assistance Coordinator is provided.

* Accesses MCSC's portal to complete referral reviews, assist patients, MTF or IRMAC staff, or other members of the healthcare team.
* Contact and inform patients if the referral request is invalid (non-covered benefits) or disapproved by MTFs or MCSC.

o Reschedule/instruct patients of other health care options within 3 business days of notification of disapproved referral, or invalid referral.

* Send communication to ordering providers when directed by RM team lead or product line nurse.

o This includes but is not limited to communication regarding requests for additional medical/clinical information, Consult closures, clarification of care requested.

* Accurately processing 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.
* Receives and enters ROFR referrals in MHS-GENESIS from the MCSC's portal for assigned specialties/product lines.

o Adheres to the defined timelines for response established by MHS, IRMAC standard operating procedures.

o Identifies and resolves ROFR issues in accordance with NCR Business Rules.

o Process all ROFR cases in the interest of optimizing care in the MTFs.

o 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.
* The Government requires a minimum of two thousand (2000) CLRS to be posted per month, with a maximum number of three thousand (3000) CLRS available per month to post.
* Review and disposition referral within 24 hrs. from the date referral was written.
* Complete 1200-1600 Referrals with less than 5 mistakes/month.
* Review 33,000 to 50,000 referrals per month.
* Provides recommendations and/or assistance to staff, patients, and other members of the healthcare team when providing guidance regarding access to care options related to patient eligibility and beneficiary status.
* Advises patients of what their referral/health treatment options and provides resources to address concerns related to Tricare benefits.
* Verifies patients' eligibility an MHS-GENESIS. Update demographic information when needed.
* Documents in MHS-GENESIS, explains appropriate options to patients when they refuse appointments within access to care (i.e., point of service, Tricare Select, to be connected to Beneficiary Counselor and Assistance Coordinator),
* Contacts product line nurse/clinic when appropriate for accommodation of highly valuable cases.
* Interfaces with the MCSC and multidisciplinary personnel as needed to ensure appropriateness of referrals.
* Submits referrals to non-network providers to TRICARE Service Center for medical necessity/appropriateness review.

o Refers to case management officials if needed.

* 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.

o Advises patients of their referral status. This may include providing references for benefit counseling assistance and/or patient advocacy.

o Advises of Line-of-Duty issues as it relates to referral management.

o Obtains pertinent information from patients/callers, referrals, physician, or other officials.

o Enters data in MHS-GENESIS.

* 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.
* Closes unused referrals as directed by DHA IPM, NCR MD policies and notifies ordering provider accordingly.
* Demonstrates understanding of the deferral process (when to defer for distance, capacity, capability, second opinion, command directed, continuity of care).

o Utilizes deferral codes appropriately.

o Understands access to care standards within the direct care system.

* Collaborates with manage care support contractor staff when civilian care is warranted.
* Orients and trains new IRMAC staff about the referral processes and timeliness

ZAI is an equal opportunity employer. In compliance with Federal and State Equal Opportunity Laws, qualified applicants are considered for all positions applied for without regard to race, color, religion, sex (including pregnancy and gender identity), national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, veteran status or any other legally protected status.

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