Job Description

Ivyhill has an immediate need for LPN Reviewers for its project located in Bethesda, MD. The qualified candidates will perform all tasks associated with referral reviews in a medical appointing call center environment.

Duties and Responsibilities

1. Review all details of referral for appropriateness, administrative and clinical completeness, and Specialty Referral Guideline (SRG) compliance for disposition per customer's guidelines.

2. Complete the referral review process upon receipt of referral.

3. Review on a regular basis: facilities’ services, medical treatment capabilities and capacity for Product Lines/Specialties assigned.

4. 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.

5. Ensure consult processing is done 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. Ensures proper use of the Direct Care System and civilian network resources.

6. Receive and make 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.

7. Initiate, follow, manage, and close all referrals within timeline standards identified by the RMC business rules and other current Government policies, regulations, or memorandums.

8. Perform referral review duties, seeking guidance from the product line nurse(s), when necessary. Review all referrals for administrative, clinical completeness and appropriateness. Collaborates with appointing center, case managers, product line nurses, providers, clinics, manage care support contractor liaison and other members of the healthcare team as needed to ensure proper use of Direct Care system and civilian network resources, as well as ensure that patients are booked at the right time, with the right provider, at the right place of care. Consult and collaborate with assigned product line nurse for clinical guidance as needed or instructed.

9. Coordinate and facilitate 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.

10. Demonstrate ability to verify patients' eligibility and ensure patients are registered in MHS-GENESIS. If patient is not showing as registered in MHS Genesis and eligible for care eligible, the contact information for DEERS, the Managed Care Contractor for Tricare and the Benefits Counseling Assistance Coordinator is provided.

11. Access MCSC’s portal to complete referral reviews, assist patients, MTF or IRMAC staff, or other members of the healthcare team.

12. Contact and inform patients if the referral request is invalid (non-covered benefits) or disapproved by MTFs or MCSC. Reschedule/instruct patients of other health care options within 3 business days of notification of disapproved referral, or invalid referral.

13. Send communication to ordering providers when directed by RM team lead or product line nurse. This includes but is not limited to communication regarding requests for additional medical/clinical information, consult closures, clarification of care requested.

14. Accurately processes referrals per the guidelines established from the order date or date consult was directed to queues managed by customer.

15. Accurately enters/processes/tracks/closes the ROFR referrals per the guidelines established.

16. Receive and enter ROFR referrals in MHS-GENESIS from the MCSC’s portal for assigned specialties/product lines. Adheres to the defined timelines for response established by MHS, IRMAC standard operating procedures. Identifies and resolves ROFR issues in accordance with NCR Business Rules. Process all ROFR cases in the interest of optimizing care in the MTFs. Reports concerns related to the ROFR referral process to team lead as needed.

17. Complete and return all Clear Legible Reports (CLR) to the ordering civilian provider within the required ROFR timelines.

18. Work with Referral Team to met the Government's requirement of a minimum of two thousand (2000) CLRS to be posted per month, with a maximum number of three thousand (3000) CLRS available per month to post.

19. Review and disposition referral within 24 hrs. from the date referral was written.

20. Complete 1200-1600 Referrals with less than 5 mistakes/month.

21. Review 33,000 to 50,000 referrals per month.

22. Provides recommendations and/or assistance to staff, patients, and other members of the healthcare team when providing guidance regarding access to care options as related to patient eligibility and beneficiary status.

23. Advises patients of what their referral/health treatment options and provide resources address concerns related to Tricare benefits.

24. Verify patients' eligibility an MHS-GENESIS. Update demographic information when needed.

25. Document in MHS-GENESIS, explains appropriate options to patients when they refuse appointments within access to care (i.e., point of service, Tricare Select, be connected to Beneficiary Counselor and Assistance Coordinator).

26. Contact product line nurse/clinic when appropriate for accommodation of high valuable cases.

27. Interface with the MCSC and multidisciplinary personnel as need to ensure appropriateness of referrals. Submits referrals to non-network providers to TRICARE Service Center for medical necessity/appropriateness review.

28. Refer to case management officials if needed.

29. Routinely monitor referral management voicemail to ensure patient calls are returned within the guidelines established.

30. Receive and appropriately forwards clinical concerns from patients to product line nurse or RM Leadership.

31. Advise patients of their referral status. This may include providing references for benefit counseling assistance and/or patient advocacy. Advises of Line-of-Duty issues as it relates to referral management. Obtains pertinent information from patients/callers, referrals, physician, or other officials. Enters data in MHS-GENESIS.

32. Provide information about EPRO to requestors outside the NCR requesting care within the NCR.

33. Assist Medicare beneficiaries in coordinating their medical care within the Direct Care System.

34. Close unused referrals as directed by DHA IPM, NCR MD policies and notifies ordering provider accordingly.

35. Understand the deferral process (when to defer for distance, capacity, capability, second opinion, command directed, continuity of care). Utilizes deferral codes appropriately. Understands access to care standards within the direct care system. Collaborates with manage care support contractor staff when civilian care is warranted.

36. Orients and trains new staff about the referral processes and timeliness.

Requirements

Qualified candidate must have a minimum of an associate degree and 2 years of experience, which demonstrates the ability to perform the duties of the position working in a MHS referral management center or clinic Medical Claims or as stated in number 1 below. Will possess a Licensed Practical Nurse Certification/Licensure. Qualified candidate must:

1. LPNs must have a current, active, full, and unrestricted License to practice nursing in accordance with State, and 2 years of clinical nursing experience is required. Board requirements. License cannot be under investigation nor have any adverse action pending from a Nursing State Board or national licensing/certification agency. Must maintain license.
2. 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-base guidelines identified by the MHS.
3. The Contractor must have in knowledge of medical terminology, ready to learn MHS, VA-DOD Sharing Program, TRICARE, HIPAA, release of medical information.
4. Possess excellent oral and written communication skills, interpersonal skills, superior customer service and organizational skills. Have working knowledge of computers, specifically the Internet, Microsoft Word, Excel, PowerPoint, Access, and Windows.
5. Must have an associate 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 Medical Claims or as stated in number 1.
6. Work Environment/Physical Requirements. The work can be sedentary. However, there may be some physical demands. Requirements include standing, sitting, or bending. Individual will be required to walk throughout the workplace and other military facilities.

This posting closes Tuesday, 10/08/2024 at 6:00 PM.

Benefits

Ivyhill has a competitive benefits program which includes medical, dental and vision; Life and AD&D insurance; Short- and Long-Term Disability; supplemental Life insurance and a 401(k) Plan.

Ivyhill 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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