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. Spectrum Healthcare Resources is proud to be an equal opportunity employer, welcoming applications from all qualified individuals, regardless of race, color, religion, sex, national origin, disability status, protected veteran status, or any other protected characteristic.