LICENSED PRACTICAL NURSE -- REFERRAL MANAGEMENT CENTER
SUMMARY: This Licensed Practical Nurse will provide utilization management activities in the Referral Management Center.
-Reviews referrals for administrative, clinical completeness and appropriateness. Validates requested medical service, and authorizes surgery/medical procedures, laboratory, radiology, pharmacy, and general hospital procedures and regulations. Collaborates with TRICARE Regional Office Clinical Liaison Nurse and MTF Liaison to address any process issues or concerns.
-Schedules referral appointments in accordance with Air Force Access to Care Standards within the direct care system or outside the MTF with network/non-network providers. Ensures appointing is done within the Access to Care standards for 90% of all referrals.
-Coordinates with specialty referral clinics (internal or external) to obtain special patient instructions and/or tests required prior to appointment. Provides pre-appointment instructions to patients as well as the details regarding their referral appointment (i.e., date/time, provider, and location). Ensures patients receive necessary documentation appropriate for the referred medical care visit.
-Locates referral requests and ensures appropriate documents are available prior to all specialty appointments. Prints diagnostic reports and/or treatment profiles as necessary.
-Verifies eligibility of beneficiaries using Defense Eligibility Enrollment Reporting System (DEERS).
-Facilitates referral activities by participation in multidisciplinary team activities. Initiates/coordinate communication between beneficiaries, team members, internal staff and providers, network/outside providers and ancillary health care workers. Provides timely, descriptive feedback regarding utilization review issues.
-Reviews and enters first right of refusal referrals into CHCS and database within one(1) business day of the date of the referral.
-Interfaces with the Managed Care Support Contractor (MCSC) and multidisciplinary personnel as need to ensure appropriateness of referrals. Submits referrals to non-network providers to TRICARE Service Center (TSC) for medical necessity/appropriateness review.
-Performs data collection and review to identify areas requiring intensive management. Refers to case management officials if needed.
-Receives and makes patient telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. Routinely monitors referral management CHCS queue to ensure patients are being called that do not utilize the RMC walk-in service.
-Contacts patients in event referral requests are invalid, disapproved by second level review/MCSC and reschedules patients as soon as possible or instructs patients of other health care options.
-Receives and appropriately forwards clinical phone consult requests from patients.
-Advises patients of what their referral/health treatment options are as related to their eligibility per beneficiary status and covered benefits. This includes eligibility for travel benefits.
-Coordinates with Air Force Aerovac units to make travel arrangements with the Global Patient Movement Requirements Center using the TRANSCOM Regulating and Command and Control Evacuation System as indicated. Ensures Aerovac personnel arrange travel orders and non-medical attendants as required for the patient and the patient is informed.
-Advises on Line-of-Duty issues.
-Obtains pertinent information from patients/callers, referrals, physician or other officials. Enters data in CHCS, AHLTA, Referral database, and other office automation software programs as appropriate.
-Tracks referral reports after appointments are kept. Ensures that results from other MTFs and from network/non-network providers are returned to the referring provider and to the medical record within required timelines and follow up with as necessary. Documents that paper referral results are properly filed in patient's health record.
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