Location
Osan-si, Gyeonggi-do, South Korea
Company Description
Entourage Consulting supports the US government. We provide comprehensive civilian staffing solutions to contract and procurement offices of US Government installations around the world. With our Headquarters in San Antonio, TX and our APAC office in Tokyo, Japan we effectively help the U.S. government with contract staff augmentation and locum services of civilian professionals. Entourage is a veteran owned fully licensed total service Provider with more than 40 years’ experience working with the US military and government.
Description of Services
Successful candidate shall provide all services, labor, and other items required to accomplish performance of Case/Utilization Manager duties as specified, in strict accordance with all terms conditions, general and special provisions, specifications, and attachments contained herein or incorporated by reference, as described in this Performance Work Statement (PWS) except those items specified as government furnished property and services.
General Scope of Work
• Perform a full spectrum of services as a Case/Utilization Manager to ensure DoD beneficiaries receive timely, appropriate, cost effective, and quality care.
• Possess the required education, training, experience, and documented current competence for a Case/Utilization Manager.
• Possess sufficient, interpersonal relationship and social sensitivity such that he/she can relate constructively to a variety of patients from diverse backgrounds.
Specific Tasks
• Proactively identify and evaluate patients and families for case management from a variety of different sources such as discharge/disposition planning, referrals, the Medical Evaluation Board (MEB) process, the healthcare system, employers and facility staff.
• Conduct systematic, on-going, thorough collection of patient’s physical, emotional, psychological, social and medical status and information via direct patient contact and other relevant sources such as professional and nonprofessional caregivers, medical records, family/caregiver interviews.
• Develop an appropriate patient-specific plan of care to include short and long term goals, objective and actions. Coordinates, collaborates, and obtains approval of the plan among the patient, family/caregiver, primary provider and other members of the healthcare team.
• Guide the patient and family/caregiver through the healthcare system, maximizing use of resources. Coordinate and execute the plan of care, optimizing access to appropriate services. Ensure necessary referrals are ordered by the appropriate discipline and coordinated. Serve as an advocate for, and ensure education is provided to, the patient and family/caregiver as required. Promote adherence to treatment plans for improved healthcare outcomes. This may include the need to visit patients in the Host Nation medical facilities, during duty hours, in order to better grasp patient’s medical condition and status.
• Ensure coordination of care delivery processes, to include alternate healthcare settings and the environment, for the purposes of enhancing the patient’s health and wellness, safety, productivity, and quality of life, and for providing the most beneficial, cost-effective health care. Develop, utilize and maintain a variety of military and community resources to optimize access to services and medical care. Ensure timely and appropriate provision of care.
• Document and update the treatment plan as needed in accordance with existing DoD, AF, local facility and other agency guidelines. Maintain documentation and data collection in accordance with DoD, AF, local facility and other specified agency guidelines. Conduct and/or participate in program evaluation as directed.
• Monitor and evaluate: patient’s adherence and response to the treatment plan; timeliness of patient and family/caregiver contact and follow-up; identification of variances, patterns or trends from established practice guidelines and/or standards; established outcome measurements; results of interventions, treatment delivery and timeliness of care; and utilization of resources. Monitor and evaluate the facility’s case management program per DoD, AF and local policies and guidelines.
• Coordinate and participate in interdisciplinary team meetings, designated facility meetings, and Care Coordination meetings. Share knowledge and experiences gained from own clinical nursing practice and education relevant to nursing and case management.
• Participate in the orientation, education and training of other staff. May serve on committees, work groups, and task forces at the facility.
• Complete medical record documentation and coding, and designated tracking logs and data reporting as required by local MTF/AF/DoD instructions, policies and guidance.
• Complete all required electronic medical record training, MTF-specific orientation and training programs, and AF/DoD mandated Case Management training.
• Develop and implement a comprehensive Utilization Management plan/program in accordance with the facility’s goals and objectives.
• Perform data/metrics collection on identified program areas; analyzes and trends results, including over- and underutilization of healthcare resources. Identify areas for improvement and cost containment. Report utilization patterns and provides feedback in a timely manner.
• Analyze medical referrals/appointments and general hospital procedures and regulations by monitoring specialty care referrals for appropriateness, covered benefits, and authorized surgery/medical procedures, laboratory, radiology and pharmacy.
• Perform medical necessity review for planned inpatient and outpatient surgery; and perform concurrent review to include length of stay (LOS) for the facility’s inpatients using appropriate criteria.
• Review previous and present medical care practices for patterns; trends incidents of under- or overutilization of resources incidental to providing medical care.
• Act as referral approval authority for designated referrals per local/AF/DoD/national guidance and standards. Refers all first-level review failures to the Chief of Medical Staff (SGH) or other POC for further review and disposition.
• Verify eligibility of beneficiaries using Defense Eligibility Enrollment Reporting System (DEERS). Obtain pertinent information from patients/callers and updates data in CHCS, AHLTA, local referral database, and other office automation software programs as appropriate and directed.
• Ensure and monitor specialty care referrals for appropriateness, medical necessity, and if the appointment, diagnostic testing, or procedure requested is a covered benefit according to appropriate health plan. If unsure, coordinate with TRICARE Regional Office Clinical Liaison Nurse or reviews TRICARE Operations Manual.
• Receive and make patient telephone calls, written, or e-mail correspondence regarding specialty clinic appointments and referrals following MTF-specific processes.
• Routinely monitor referral management Composite Health Care System (CHCS) queue to ensure patients referrals are appointed and closed out.
• Ensure Line of Duty paperwork is on file prior to authorization for all reserve and guard member referrals.
• Keep abreast of MTF and local market services and capabilities. Update capability report as needed/directed.
• Conduct referral reconciliation report as directed, identifying all open referrals and provides notification to appropriate personnel for resolution.
• Monitor active duty, reserve/guard inpatient admissions to MTF and host nation civilian hospitals, coordinating care between facility, PCM and command. Notify Patient Administration Element as required.
• Serve as a liaison with headquarters, TRICARE regional offices, MTF staff and professional organizations concerning Utilization Management practices.
• Collaborate with staff/departments, including, but not limited to: Executive Management, Resource Management, Medical Records, Patient Administration, Group Practice Managers, Health Care Integrators, Coders/Coding Auditors, Population Health Nurse Consultants, Medical Management, Referral Management, TRICARE Operations, patient care teams, Quality Improvement, and the Managed Care Support Contractors.
• Maintain a level of productivity and quality consistent with: complexity of the assignment; facility policies and guidelines; established principles, ethics and standards of practice of professional nursing; the Case Management Society of America (CMSA); American Accreditation Healthcare Commission/Utilization Review Accreditation Commission (URAC); CAMH; (AAAHC); Health Services Inspection (HSI); and other applicable DoD and Service specific guidance and policies. Must also comply with the Equal Employment Opportunity (EEO) Program, infection control and safety policies and procedures.
• Provide satisfactory patient customer service, maintain a positive attitude and uphold suitable character as established by the AF guidelines.
Experience/Knowledge
• Case Utilization Manager shall have at least one (1) year of clinical nursing experience within the last five (5) year.
• Ability to work resourcefully and creatively, to think independently, and to exercise sound judgment in a complex and dynamic environment.
• Ability to work with minimal guidance; seeks guidance on only the most complex tasks.
• Ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action.
• Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.
• Knowledge and experiences gained from own clinical nursing practice and education relevant to nursing and case management.
• Knowledge of health insurance industry trends, technology and contractual arrangements.
Education/Certifications:
• Case/Utilization Manager shall be a graduate of a Baccalaureate Degree program in nursing from a nationally.
• Possess and maintain throughout the course of the contract a current Basic Life Support (BLS) certification through an American Heart Association approved training program. The MTF will provide BLS refresher courses.
• Case/Utilization Manager shall possess a certification of current physical examination. The physical examination shall be current within 12 months prior to contract award. Initial documentation is required for: MMR (immunization or titer levels for Rubella and Rubeola), history of chicken pox disease or positive titer (varicella vaccination must be accomplished if lack of immunity), Tetanus Diphtheria (Td), TB Mantoux skin test (IPPD) if positive, minimum requirement will be follow-up with the Contractor’s physician and a chest x-ray. This certification shall state the date on which the examination was completed, the name of the doctor who performed the examination, and a statement concerning the physical health of the individual. The certification shall also contain the following statement: “(insert C/UM’s name) is suffering from no contagious diseases to include, but not limited to, Tuberculosis, Hepatitis, and Venereal Disease”. A physician must provide documentation of “no active respiratory disease.” It is the contractor’s responsibility to pay for any medical examinations necessary to ensure this public health compliance requirement is met.
License:
• Case Utilization Manager shall possess and maintain throughout the course of the contract a current, active, valid, unrestricted (with no limitations, stipulations, or pending adverse actions) state nursing license in one of the fifty United States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, or the U.S. Virgin Islands. License must be recognized and accepted by the U.S. State or Territory of practice in accordance with governing regulations.