Referral Management Health Care Coordinator - TM3 Solutions, Inc.
Bethesda, MD
About the Job
ROLE AND RESPONSIBILITIES
Referral Management Health Care Coordinator. The Licensed Practical Nurse/Referral Management Coordinator will provide care coordination and referral management activities in 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 Registered Nurse.
• License cannot be under investigation nor have any adverse action pending from a Nursing State Board or national licensing/certification agency. All licenses must remain current, valid and unrestricted during contract employment.
• 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.
• 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 in the Military Health System.
• 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.
DUTIES AND RESPONSIBILITIES:
• 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.
• Send communication to ordering providers when directed by RM team lead or 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
Contractor’s portal, MHS GENESIS, and AVAYA systems.
• Accurately processes 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 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.
• Document and update all ROFR cases in the IRMAC database. Prepare, review, consolidate, and report data to demonstrate understanding of the ROFR Process. Accurate data entry and attention to detail. Review monthly reports on ROFR data with data analysts, leadership, and team lead.
• Educate NCR providers, staff, and patients on the ROFR process as needed.
• Maintains the MTFs Specialty Capability Table and Coarse 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. Ensure 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 protocols and required Access to Care Standards within the 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.
• 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.
• 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.
• Closes unused referrals as directed by DHA IPM, NCR MD policies and notifies ordering provider
• accordingly.
• 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.
• 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.
• On occasion, is able to take on Team Lead responsibilities as requested by the Referral Management Team Lead.
EDUCATION AND SPECIAL REQUIREMENTS:
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.
Referral Management Health Care Coordinator. The Licensed Practical Nurse/Referral Management Coordinator will provide care coordination and referral management activities in 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 Registered Nurse.
• License cannot be under investigation nor have any adverse action pending from a Nursing State Board or national licensing/certification agency. All licenses must remain current, valid and unrestricted during contract employment.
• 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.
• 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 in the Military Health System.
• 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.
DUTIES AND RESPONSIBILITIES:
• 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.
• Send communication to ordering providers when directed by RM team lead or 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
Contractor’s portal, MHS GENESIS, and AVAYA systems.
• Accurately processes 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 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.
• Document and update all ROFR cases in the IRMAC database. Prepare, review, consolidate, and report data to demonstrate understanding of the ROFR Process. Accurate data entry and attention to detail. Review monthly reports on ROFR data with data analysts, leadership, and team lead.
• Educate NCR providers, staff, and patients on the ROFR process as needed.
• Maintains the MTFs Specialty Capability Table and Coarse 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. Ensure 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 protocols and required Access to Care Standards within the 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.
• 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.
• 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.
• Closes unused referrals as directed by DHA IPM, NCR MD policies and notifies ordering provider
• accordingly.
• 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.
• 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.
• On occasion, is able to take on Team Lead responsibilities as requested by the Referral Management Team Lead.
EDUCATION AND SPECIAL REQUIREMENTS:
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.
Source : TM3 Solutions, Inc.
