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 after the successful completion of 120 days onsite.

Find out more about this role by reading the information below, then apply to be considered.

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 compliance 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.
• 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.
• 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.
• Accesses MCSC’s portal to complete referral reviews, assist patients, MTF or IRMAC staff, or other members of the healthcare team.
• Contacts and informs patients if the referral request is invalid (non-covered benefits) or disapproved by MTFs or MCSC.
• Accurately processing referrals per the guidelines established from the order date or date consult was directed to queues managed by IRMAC.
• Completes and returns all Clear Legible Reports (CLR) to the ordering civilian provider within the required ROFR timelines.
• 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.
• Documents in MHS-GENESIS, explains appropriate options to patients when they refuse appointments within access to care.
• 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.
• Routinely monitors referral management voicemail to ensure patient calls are returned within the guidelines established.
• 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.
• Demonstrates understanding of the deferral process (when to defer for distance, capacity, capability, second opinion, command directed, continuity of care).
• 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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