Registered Nurse (RN) - Referral Manager

Accelerating the delivery of care and providing superior force health readiness across the Military, Federal, and Civilian landscapes. Goldbelt Glacier is committed to providing transformative and comprehensive health operational capabilities to support customers across scientific, clinical, technological, and program management areas. 

As a part of the Goldbelt Glacier Team, you will be supporting the Naval Logistics Command with medical services for active-duty military personnel, their dependents, eligible DoD civilian employees, and other eligible beneficiaries designated by the Government. As a HealthCare Worker (HCW), you will be assigned to either a Military Treatment Facility (MTF) or other Federal medical treatment facilities in Japan.

• Obtain patient health and developmental history. 

• Collect and record all examination data in proper format for review, approval and/or recommendation by supervisor. 

• Differentiate between normal findings and those that require consultation and/or referral. 

• Request X-Rays, perform laboratory, and medical photos tests as deemed necessary. 

• Assist with the formulation of a health care plan for patients presenting for treatment to the emphasizing self-care responsibility through the participation of the patient, family, physician and other health care professionals. 

• Collaborate with physicians and nursing staff in the health care unit to coordinate care with patients that have common acute conditions, chronic illnesses, and minor trauma.  

• Perform duties as directed by government supervisor in the proactive management of the population with emphasis on prevention of disease and promotion of health and wellness.   

• Maintain patient records in accordance with MTF requirements.

• Request and maintain unit supplies, equipment, etc. as directed by Government Supervisor.

• Adhere to all departmental and hospital safety guidelines.

• The HCW shall document all patient cases and provide those cases, once complete to the administrative staff to ensure that patient encounters capture the Department’s workload in Composite Health Care System (CHCS)/Armed Forces Health Longitudinal Technology Application (AHLTA) using Medical Expense, Referral Management System (RMS), and Performance Reporting System (MEPRS) code BAZA.

• Participate in meetings to review and evaluate the care provided to patients, identify opportunities to improve the care delivered, and recommend corrective action when problems exist.  Should a meeting occur outside of the HCW’s regular working hours, the HCW shall be required to read and initial the minutes of the meeting.

• The HCW shall provide important component of primary healthcare through direct social work services, consultation, collaboration and referral. 

• Patient teaching and health advocacy are key components of practice.   

• Assist in developing and refining referral management (RM) to support medical management initiatives at the military treatment facility (MTF).  

• Assess, monitor and evaluate and assist in processing up to 200 monthly referrals for authorization.  The contractor shall review specialty care referrals for clinical appropriateness, covered benefit, and administrative and medical completeness following MTF and BUMED guidelines and TRICARE policy.  The HCW shall input and retrieve patient information for each referral, through the use of various computer systems include Composite Health Care System (CHCS), Armed Services Health Longitudinal Technology Application (AHLTA), Care Point Healthcare Application Suite (CHAS), Defense Enrollment Eligibility Reporting System (DEERS) and other work programs that are in use in the Referral Management Center. 

• Refer to a physician advisor for clinical review if the HCW and physician cannot reach an agreement on the processing of a referral within two business days. Timelines shall be monitored through computer reporting systems such as CHCS, AHLTA, CHAS and TRICARE Reports.   

• Elevate referrals to the medical manager and physician advisor for higher level of review when there is uncertainty in medical necessity and covered benefit. All referrals for routine continental US care will be elevated to the medical manager and director of medical services. 

• Communicate between physician reviewer and the requesting provider in regards to preauthorization.  

• Submit monthly, quarterly, and yearly utilization reports using CHCS, AHLTA, CHAS, and TRICARE Reports. The HCW will report on referral trends, patterns or incidents of under- and/ over-utilization of resources, network leakage, purchased care costs, network care recapture, continuity of care, and customer satisfaction for all beneficiaries.  The HCW will discuss patterns and trends with MTF providers and the Directorate of Healthcare Business leadership to educate and improve processes. The HCW shall present these reports to all medical staff with recommendations for efficient use of resources. 

• Evaluate monthly through prospective, concurrent, retrospective review, focused reviews, clinical pathways and clinical practice guidelines for performance outcomes of clinical care.  The HCW will review five defer to network consults per month to determine consult outcome and if clinical practice guidelines were met. If not met, the HCW will develop and implement a plan of action for consult management to ensure clinical practice guidelines are met. 

• Identify and communicate all adverse trends and referral management discrepancies in a written report via the chain of command and effectively communicate both verbally and in writing with the requesting physician(s) for clarification and correction.  The report is to be submitted when trend/discrepancies identified. 

• Manage the referral processing center for all beneficiary categories (Active Duty, Active Duty Family Members, Retirees, and their family member, survivors, Department of Defense Civilians, Contractors) of patient clinical referrals and care authorizations to health care specialists in either the direct care or purchased care systems. 

• Provide departmental, directorate, and command performance improvement processes commensurate with this position.  The HCW will be responsible for participating in monthly education programs, quality assurance functions and process action teams to improve the operations of the referral management center. 

• Referral management services will be performed in a managed care environment.  The RN referral manager shall adhere to clinical practice guidelines, BUMED Referral Management Guidelines; Referral Management policies; TRICARE policies and procedures; and ICD and DRG codes. 

• Process the patient Audio Communicator report and enter the results into individual patient records. 

• The HCW shall be responsible for the Supplemental Health Care Program (SHCP)/Move It program and research Wisconsin Physicians Service (WPS) Insurance Corporation claims pending for authorization for active duty service members enrolled to TRICARE overseas.  The HCW will research each claim to determine whether the care should be authorized or denied based on investigation of the episode of care, TRICARE policy of covered benefits and medical necessity.  Each claim will be authorized/denied within ten calendar days from its posting by the overseas claims processor (WPS).  The RN referral manager will resolve discrepancies of claims and communicate discrepancies with the medical manager. 

• Schedule specialty care appointments and provide pre-appointment instructions to the patient according to clinical information provided in the consult, patient’s medical record, clinical practice guidelines, BUMED and MTF policies. 

• Maintain contact with patients according to established protocols to communicate appointments and individual referrals.  The HCW will review and assist in the resolution of patient complaints, gather information and coordinate with patient and appropriate officials or facilities in order to resolve issues.  The HCW shall provide excellent customer service and maintain good relations inside and outside the directorate through positive communication and work coordination. 

• Provide the MTF with up-to-date information for the MTF Service Availability Report (SAR).  The HCW shall utilize the SAR to recapture care and maximize the capabilities of the MTF by redirecting care.  The RN referral manager will serve as a resource to assist the primary care manager with interpretation of referral guidelines and criteria.  The contractor shall participate in monthly in-service training for healthcare practitioners and administrative staff on subjects of referral management and utilization management services. 

• Provide the MTF with a report on internal referral management bi-weekly using CHAS.  This report will be disseminated to the medical staff and directorate of healthcare business leadership.  The RN referral management will manage discrepancies and collaborate with clinic managers to ensure access to clinical care is delivered according to BUDMED policies. 
• Metrics:
  • Referral Management RN will respond to patient-initiated & provider-initiated messages within one business day.
  • 90% of referrals will be accepted within one business day.
  • Achieve and maintain a monthly average of DTNR return rate of less than 5%.
  • Review ten defer to network consults per month to determine consult outcome and if clinical practice guidelines were met.
  • Maintain a 95% accuracy rate in referral determinations.
  • Process 100% of urgent referrals same day as received.
  • Facilitate at least 4 training sessions per year for internal staff, with 80% attendee satisfaction.
  • Participate in at least 95% of scheduled meetings and contribute to strategic discussion

• Possess education as follows:  Either (a), a bachelor’s degree in Nursing; or (b) a diploma graduate in Nursing; or (c) an associate degree in Nursing from an accredited university. 

• Possess and maintain a current unrestricted license to practice as a Registered Nurse in any one of the 50 states, District of Columbia, the Commonwealth of Puerto Rico, Guam or the U.S. Virgin Islands. The licensing exam taken by the registered nurse must be the National Council of Licensing Examinations – Registered Nurse (NCLEX-RN). The HCW is responsible for complying with all applicable state licensing regulations. 

• Possess two years experience as a Registered Nurse within the last three years. 

• Possess a valid driver’s license and a personal vehicle for use under the contract. 

• Provide two letters of recommendation written within the preceding two years from practicing providers, supervisors or program administrators attesting to the HCW’s professional skills, competencies, patient rapport, training abilities, etc. Recommendation letters must include; name, title, phone number, date of recommendation, address and signature of the individual providing the recommendation. 

• A thorough understanding of the military lifestyle and experience working with military family members.
• Working knowledge of relevant military, state, federal, and local laws and resources.
• Highly developed written, oral, and presentation communication skills.
• An active security clearance is preferred.

Pay and BenefitsAt Goldbelt, we value and reward our team's dedication and hard work. We provide a competitive base salary commensurate with your qualifications and experience. As an employee, you'll enjoy a comprehensive benefits package, including medical, dental, and vision insurance, a 401(k) plan with company matching, tax-deferred savings options, supplementary benefits, paid time off, and professional development opportunities.

• Maintain a level of productivity comparable with that of other individuals performing similar services.
• Adhere to and comply with the Department of the Navy, Bureau of Medicine and Surgery, and local instructions and notices in effect during the term of the contract.
• Practice aseptic techniques as necessary; comply with infection control guidelines to include the proper handling, storage, and disposal of infectious wastes, and the use of universal precautions to prevent the spread of infection.
• Function with an awareness and application of safety procedures.
• Apply an awareness of legal issues in all aspects of patient care and strive to manage situations in a reduced risk manner.
• Exercise awareness and sensitivity to patient/significant others' rights, as identified within the MTF.
• Maintain an awareness of responsibility and accountability for own professional practice.
• Maintain DoD email account as directed by government supervisor.
• Exercise appropriate delegation of tasks and duties in the direction and coordination of health care team members, patient care, and clinic activities.
• Undergo an orientation and shall complete mandatory Navy and DoD on-line training as required.
• Be able to comply with all applicable Federal, State, and local laws, Department of Defense, Department of Navy, Bureau of Medicine and Surgery, and MTF instructions and policies.
• Proficiency in Microsoft Office software applications including Word, Excel, Access, PowerPoint, and Outlook.