Registered Nurse (Non-Practicing)

Company: Zimmerman Associates, Inc.
Location: Bethesda
Posted on: April 5, 2025

Job Description:

Registered Nurse will have overall responsibility for timely review of Right of First Refusal (ROFR) requests, review of Specialty Care Referrals, sustaining up-to-date Specialty Clinic Referral Review tools and booking guidance, complying with Referral and Authorization Business rules, tracking, and resulting of referrals, and full use of Referral Management (RM) information management systems. Will conduct reviews for capacity, capability, medical necessary, deferral to network, and right of first refusal activities.

All the relevant skills, qualifications and experience that a successful applicant will need are listed in the following description.

This is an onsite employment opportunity. However, consideration will be provided for teleworking upon customer's approval.

Duties and Responsibilities

Review all details of referral for suitability, administrative and clinical completeness, and required tests and pre-work for disposition per IRMAC guidelines. Stay abreast of facilities' services, medical treatment capabilities and capacity for Product Lines/Specialties assigned. Proactively collaborates with Managed Care Support Contract (MCSC), Product Line Leaders, RM, Appointing Center(s), other members of the healthcare team and MTF points of contact to address any process issues or concerns.
Review referrals within the established guidelines from a market approach utilizing MHS-GENESIS, MCSC Portal and other EHR's or databases when needed. Develop, maintain and update referral review tools as needed.
Understand the deferral process (when to defer for distance, capacity, capability, second opinion, command directed, continuity of care) and utilize deferral codes appropriately.
Elevate patients' concerns, more complex clinical cases to Team Lead, Product Line leadership, or Referral Management (RM) leadership as appropriate.
Receive and initiate telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. Routinely monitor and process referral management MHS-GENESIS queues to ensure consults are being processed within the established guidelines.
Advise patients of their referral status to include providing references for benefit counseling assistance and/or patient advocacy.
Approval authority for all active duty and reserve/guard referrals under the supplemental health care program. Coordinate with Medical Director, Product Line leaders, and/or RM leadership for all active, reserve and guard referrals not covered under the TRICARE benefit for approval.
Review and maintain ROFR referrals into MHS-GENESIS and database within the established guidelines for proper processing in attempts to recapture workload from the network to the MTF.
Establish and maintain good interpersonal relationships with co-workers, families, peers, and other health team members. Identify, analyze, and make recommendations to resolve problems and situations regarding referrals.
Manage and utilize multiple complex computer systems for appointment scheduling.
Assists Medicare beneficiaries in coordinating their medical care within the Direct Care System.
Performs additional duties that support the referral management process and the RM Team.



Requirements

Qualified candidate must be a Licensed Registered Nurse (RN), with an unencumbered active RN license from a State Board of Nursing and graduated from an accredited nursing program.

Must have three (3) years of clinical nursing experience. Referral Management (RM) and Utilization Management (UM) experience is preferred. Full-time employment in a nursing field within the last 24 months is mandatory.

Additionally, the qualified candidate must:

Be a U.S. Citizen.
Have 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.
Be proficient in the usage and understanding 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 excellent oral and written communication skills, interpersonal skills, superior customer service, leadership, and organizational skills.
Have a working knowledge of computers, specifically the Internet, Microsoft Word, Microsoft PowerPoint, Microsoft Access, Microsoft Excel, and Windows.

Keywords: Zimmerman Associates, Inc., Bethesda , Registered Nurse (Non-Practicing), Healthcare , Bethesda, Maryland