RN - Utilization Manager

Spectrum Healthcare Resources is excited to offer a potential career opportunity for an Utilization Manager Registered Nurse at the Cannon Air Force Base. This civilian position is an outstanding chance to contribute to the health and well-being of our military members while enjoying a rewarding work-life balance and a supportive patient community.

Join us in making a significant impact on the lives of those who serve our country, with a focus on quality care and professional development!

Requirements:

Bachelor of Science in Nursing from an accredited program.
• Active, full, and unrestricted Registered Nurse license in the United States.
• 6 years of clinical nursing experience.
• 1 year of experience in Utilization Management or a similar role.
• Proficient in applying medical criteria like InterQual or Milliman guidelines.
• Knowledgeable in medical coding systems (APGs, DRGs, ICD-9, CPT-4).
• Strong communication, interpersonal, and computer skills.

Job Responsibilities:

• Handle Right of First Refusal (ROFR) requests promptly.
• Manage and screen specialty care referrals ensuring they meet Cannon AFB's criteria.
• Ensure all referral activities align with Cannon AFB's business rules and healthcare standards.
• Keep up-to-date records such as the Specialty Clinic Booking Guidance, MTF Capabilities Report, and ROFR Reports for Cannon AFB.
• Track, document, and follow up on referrals using Cannon AFB's designated systems.
• Perform reviews to determine medical necessity, pre-authorizations, and handle medical appeals.
• Aid in the recovery of funds from insurance carriers for services provided at Cannon AFB.
• Utilize systems like CHCS, AHLTA, MHS GENESIS, or others as specified by Cannon AFB for managing referrals.
• Ensure all data entries are precise and timely.
• Collaborate with Cannon AFB's executive staff, clinical operations, resource management, medical records, and quality division to ensure efficient resource use and cost management for beneficiaries.
• Train other Referral Management Center staff at Cannon AFB.
  

Company Overview:

At Spectrum, we leverage over thirty-five years of experience to deliver innovative and cost-effective solutions for federal agencies. Certified by the Joint Commission, we are committed to the highest standards of service and reliability.

EOE/Disabled/Veterans