Registered Nurse - Utilization Management - Fort Carson, CO

Job Title : Registered Nurse Utilization Management (RN-UM)

Location : Colorado Military Health System (CMHS), Fort Carson, CO, 80913

Work Schedule : Monday Friday, 8-hour shifts between 0600 1700, excluding federal holidays

Qualifications :

Education : Graduate of an accredited school of nursing (BSN preferred).

Experience :

Minimum of 1 year of Utilization Review / Management experience.

Minimum of 3 years of clinical nursing experience.

Experience with TRICARE and military healthcare systems is highly desirable.

License / Certification : Current, full, active, unrestricted RN license in a U.S. jurisdiction; BLS certification required.

Other Requirements : Must be a U.S. Citizen; excellent analytical, communication, and organizational skills.

Responsibilities :

Conduct utilization management reviews to ensure healthcare services are medically necessary, appropriate, and cost-effective.

Act as a liaison with providers, referral centers, and TRICARE contractors to ensure patients receive care at the appropriate level and location.

Apply clinical knowledge to review medical necessities for specialty referrals, inpatient admissions, and outpatient services.

Prepare and analyze reports on utilization data and healthcare trends to identify inefficiencies or over / under-utilization.

Identify high-cost or complex cases, collaborating with case managers and providers to optimize patient care planning.

Ensure patient care complies with TRICARE access-to-care standards and DHA utilization policies.

Educate providers and staff on referral management processes and utilization criteria.

Support process improvement initiatives to enhance referral and utilization management across the CMHS.

Maintain accurate documentation of all utilization management activities in EHR systems.

Protect patient confidentiality and comply with HIPAA and DoD privacy requirements.

Prime Physicians is a physician-led, The Joint Commission (TJC) Accredited, ISO 9001 certified and CMMI Level 3 appraised organization. Our commitment extends beyond traditional consulting and management services, offering comprehensive solutions to hospitals, health systems, and federal government agencies. At the heart of our operations is the ultimate goal to deliver high-quality patient care. Driven by a mission to catalyze healthcare transformation and innovation, we offer an array of services designed to redefine the healthcare landscape. From program and project management to strategic planning, we enhance operational efficiency and streamline business processes. With Prime Physicians, the future of patient care is in skilled and dedicated hands, leading the way towards a more efficient, effective, and compassionate healthcare system.