Registered Nurse – Referral Management Center

Entourage is accepting resumes for this role:

Registered Nurse – Referral Management Center
Place of Performance: Japan

Specific Tasks:

• Conduct reviews for medical necessity, preauthorization, medical appeals, collection and recovery from insurance carriers, and right of first refusal activities.
• Monitors specialty care referrals for appropriateness, covered benefit, and authorized hospital procedures and Access to Care standards for 90% of all referrals.
• Orients and instructs other Referral Management Center (RMC) staff.
• Assists in locating specialty providers in routine or STAT situations.
• Coordinates with SGH for all active, reserve and guard referrals not covered under the TRICARE benefit for approval.
• Reviews and enters first right of refusal referrals into CHCS and database within one (1) business day of the date of the referral for proper processing in attempts to recapture workload from the network to the MTF.
• Ensures summaries for all specialty referrals scheduled within the MTF are closed out in the referral database and given to the requesting provider within 72 hours.
• Processes the TRICARE Regional Office reconciliation report daily, identifies all open referrals and ensures resubmission. Ensures all referrals are reviewed and dispositioned in the appropriate manner (both electronically and manually).
• Prepares and submits monthly reports from encounter forms and ad hoc reports.
• Participates in in-services and continuing education programs. Briefs applicable data/slides to provider staff, executive staff, newcomers, as appropriate.

Qualifications:

• Degree: Associates Degree of Nursing.
• Education: Graduate from a college or university accredited by Accreditation Commission for Education in Nursing (ACEN), the Commission on Collegiate Nursing Education (CCNE).
• Experience: Current experience required is three years within the last four years as a registered nurse.
• Licensure: Current, full, active, and unrestricted license to practice as a registered nurse.