Nurse (Utilization Management / Referral Management)

Ensure that all emergent referrals are submitted to the Managed Care Support Coordinator (MCSC) within same business day and coordinates to expedite patient appointment for all emergent referrals. Evaluate the appropriate level of care for referrals and TRICARE Plus network referrals by reviewing the referrals, health care plans and historical care provided to the patient. Serve as a resource and assist providers with interpretation of guidelines and criteria for referrals and TRICARE Plus referrals. Consult with providers regarding specific anomalies to the network management plan. Educate medical staff on proper referral inputs and necessary medical language within referrals. Manage day-to-day operations of the Referral Management Center by providing clinical guidance and direction on tracking and processing of referrals. Develop and maintain referral guidelines and business rules in coordination with IRMAC.