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Asistir a los funcionarios de la FTM para garantizar que se cumplan las normas de inspección de eficacia de la unidad a nivel operativo.\n\nAsistir en el desarrollo e implementación de un plan o programa integral de Gestión de Utilización para beneficiarios dentro de los objetivos y metas de la FTM. Este plan se basa en el uso del enfoque de 12 pasos descrito en la Guía de Gestión Médica del Departamento de Defensa (DoD).\n\nEstablecer procedimientos para realizar revisiones, incluida la identificación de los tipos de servicios de atención médica que requerirán autorización previa o revisión concurrente. Revisar las prácticas médicas actuales y anteriores según sea necesario para detectar patrones, tendencias o incidentes de subutilización o sobreutilización de recursos hospitalarios relacionados con la atención médica proporcionada a los beneficiarios.\n\nPlanificar y realizar revisiones de acuerdo con indicadores y directrices establecidos para proporcionar atención de calidad y costo-efectiva. Asegurar que las necesidades identificadas de los pacientes se aborden de forma oportuna con decisiones adecuadas. Proporcionar retroalimentación descriptiva y oportuna sobre cuestiones relacionadas con la revisión de utilización. Utilizar las mismas normas, criterios y estándares generalmente aceptados para revisar la calidad, integridad y adecuación de la atención médica proporcionada dentro de la FTM, así como su necesidad, idoneidad y razonabilidad.\n\nCumplir con el proceso estandarizado establecido de apelaciones del DCS para resolver solicitudes de reconsideración de denegaciones de atención por parte de beneficiarios basadas en determinaciones de necesidad médica, de acuerdo con las referencias (e) y (o). Después de seguir la metodología indicada para las apelaciones, la FTM también cumplirá con el proceso de notificación intermedia de su respectivo Servicio o comando conjunto, si existe, antes de pasar del nivel interno al externo de las apelaciones.\n\nCumplir con las políticas de gestión de referencias del MHS y del Departamento Militar o de los Comandos Médicos Conjuntos para gestionar referencias internas y externas. Incorporar estrategias de GM como parte de los procesos rutinarios del centro de gestión de referencias. Asegurar que los procesos monitoreen, gestionen y optimicen la demanda o capacidad (acceso).\n\nColaborar con el equipo de la MHCP para desarrollar indicadores de desempeño y procesos para condiciones clínicamente importantes, según determinen los equipos de la MHCP y el liderazgo de la FTM. Estas condiciones clínicamente importantes deben incluir, aunque no se limitan a, diagnósticos, procedimientos, servicios o beneficiarios de alto costo, alto volumen o propensos a problemas, que utilizan servicios de salud a tasas superiores al promedio y que podrían beneficiarse de intervenciones y una coordinación de atención más intensiva. Realizar la recolección de datos y métricas. Analizar datos y preparar informes para describir patrones de utilización de recursos. Presentar datos o diapositivas pertinentes al personal médico, personal ejecutivo y nuevos empleados, según corresponda. Identificar áreas que requieran gestión intensiva o áreas de mejora.\n\nMantener informes sobre los casos que han sido denegados o que han recibido pagos reducidos de terceros y reportar perfiles de proveedores a la dirección de la FTM para acciones correctivas.\n\nActuar como enlace con la sede superior, la Oficina Regional TRICARE, la organización de acreditación nacional de la FTM, organizaciones profesionales e instalaciones comunitarias de atención médica en asuntos relacionados con la Gestión de Utilización.\n\nParticipar en programas de capacitación interna y educación continua. Presentar datos o diapositivas pertinentes al personal médico, personal ejecutivo y nuevos empleados, según corresponda.\n\nEstablecer y mantener buenas relaciones interpersonales con compañeros de trabajo, familias, pares y otros miembros del equipo de salud. Presentar todas las inquietudes a través del Director de Gestión de Utilización; ser capaz de identificar, analizar y hacer recomendaciones para resolver problemas y situaciones relacionadas con referencias. Asegurar la coordinación y comunicación entre todo el personal de GM, incluyendo personal clínico y administrativo, para garantizar una atención y servicios eficientes, efectivos y de calidad.\n\nSer productivo y desempeñarse con supervisión y dirección mínimas. Ser capaz de identificar, planificar y llevar a cabo proyectos de forma independiente, considerando los objetivos y metas del Elemento de Gestión de Utilización TRICARE. Desarrollar procedimientos y directrices detalladas para complementar las regulaciones administrativas y orientaciones del programa establecidas. Las recomendaciones se basan en el análisis de observaciones del trabajo, revisión de procedimientos y aplicación de directrices.\n\nHorario:\nLunes a viernes, 9 horas entre las 7:00 a.m. y las 5:00 p.m., con una hora de almuerzo.\nSin fines de semana ni días festivos.\n\nRequisitos\nCalificaciones mínimas:\n* Educación: Título mínimo de ASN de una universidad o colegio acreditado.\n* Experiencia: Se requiere un año de experiencia en Gestión de Utilización. Es obligatorio haber trabajado a tiempo completo como enfermero registrado durante los últimos 36 meses. Se prefiere contar con seis años de experiencia clínica en enfermería.\nDebe poseer experiencia realizando revisiones prospectivas, concurrentes y retrospectivas para justificar la necesidad médica de la atención sanitaria, con el fin de ayudar en la recaudación y recuperación de múltiples compañías aseguradoras. El proceso de revisión incluye referencias del Sistema de Atención Directa y de Atención Comprada, rondas hospitalarias para la recolección de datos clínicos, contacto con proveedores para informarles sobre pérdidas económicas por documentación faltante y proporcionar documentación para la resolución de apelaciones. Debe poseer conocimientos prácticos de Agrupamiento de Procedimientos Ambulatorios (APG), Agrupamiento por Diagnóstico Relacionado (DRG), Clasificación Internacional de Enfermedades, Versión 9 (CIE), y Terminología de Procedimientos Curren, Versión 4 (CPT-4).\n* Licencia: Licencia actual, completa, activa y sin restricciones de enfermero registrado (RN) de cualquier estado.\n* Certificaciones de soporte vital: Certificación AHA o ARC en Soporte Vital Básico (BLS).\n* Seguridad: Debe tener capacidad para aprobar una verificación de antecedentes o autorización de seguridad gubernamental.\n\nSomos un empleador que ofrece igualdad de oportunidades y un entorno libre de drogas. 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