UnitedHealthcare Military and Veterans is currently seeking a Senior Clinical Admin Nurse (Health Care Coordinator HCC). This position will be responsible for daily interaction with the Referral Management Center (RMC), Discharge Planners and Case Managers at the Military Treatment Facility (MTF).  This position is responsible for processing urgent referrals and authorization for beneficiaries requiring specialty consultation and treatment outside of the MTF.  This position is the clinical contact for the TRICARE Service Center (TSC) and responsible for clarifying all clinical issues and verify whether requested services are a covered benefit when questions arise. This position will also generate authorization letters for beneficiaries and providers as needed.

Ensuring that the notification coordinators comply with all applicable State and Federal laws and consent decrees, as well as the applicable accrediting regulatory review agencies, including but not limited to CMS, NCQA, HIPAA, and all UHC policies and procedures as applicable

***This position is based out of the William Beaumont Army Medical Center, Fort Bliss in El Paso, Texas.***

Primary Responsibilities

• Process urgent care referrals in a timely manner
• Assist the MTF with locating network facilities and difficult subspecialties
• Monitor referral queues and process referrals for  the region as needed
• Generate letters and authorizations for beneficiaries when they present to the TSC
• Provide clinical expertise to Customer Service Referral Representatives (CSSR)
• Coordinates internal reviews on denial letters to determine compliance with contractual and regulatory requirements of the TRICARE programs, while reviewing for efficiencies and effectiveness of procedures.
• Performs internal Quality Control reviews on processes and activities while developing recommendations for improvement.
• Serves as a catalyst for implementing an appropriate risk assessment process designed to identify and correct deficiencies.
• Maintain extensive knowledge of regulatory and applicable accrediting body requirements becoming a Compliance resource for the team.
• Proficient in interpreting benefits
• Maintain knowledge of State rules, contracts, and Federal legislation/regulations as well as UHG guidelines
• Establish and maintain good working relationships throughout the company to support goals and objectives.
• Demonstrate flexibility, availability, and dependability to conform to position responsibilities.
• Periodically works with the beneficiary to resolve clinical issues as it relates to referred care

Job Keywords: RN, Nurse, Referrals, beneficiary, reviews, denials, quality control, clinical, hospital, TX, Texas, El Paso, William Beaumont Army Medical Center, Fort Bliss,

• Requires current unrestricted RN licensure in applicable state
• BSN from an Accredited Nursing Institution
• 2 years+ experience in a hospital setting
• Proficient computer skills with direct experience in Microsoft Office, Word, PowerPoint, and Excel required
• United States Citizenship
• Ability to obtain favorable adjudication following submission of Department of Defense form SF86 NAC form SF86
• Demonstrated excellent written and verbal communication skills required
• Proven analytical and problem solving skills while managing multiple tasks simultaneously

Additional Assets

• Experience working in a military treatment facility and/or knowledge of the TRICARE Program preferred
• Knowledge of Milliman or InterQual is preferred
• Managed care experience or experience with a regulatory or accredited body preferred
• Ability to work independently or in a team environment
• The applicant should possess a high attention to detail, exceptional documentation abilities, and organizational skills.

As a requirement of UnitedHealth Group’s contract with the Department of Defense, this position requires U.S. citizenship and proof of favorable adjudication following submission of Department of Defense form SF86 http://www.opm.gov/forms/pdf_fill/sf86.pdf, (the National Agency Check or “NACâ€).  Successful completion of the NAC process is a requirement for continued employment in this role.  NAC processing will be initiated by our TRICARE Security Officer post-offer, and can take 3-6 months for a final decision communication from the Department of Defense.  Candidates will be allowed to begin employment with UnitedHealth Group in this role based on an interim clearance, and final results will be communicated as they are received.  Failure to obtain final NAC approval will result in termination from this role.

Careers at UnitedHealthcare Military & Veterans. When it comes to their health care, the men and women who help keep the peace deserve the greatest peace of mind. That’s why UnitedHealthcare is the organization that’s called on to serve them and their loved ones. We’re all about finding better ways to help improve their lives no matter where life may take them. So our career opportunities take challenge to a higher level. If you have a commitment to quality that mirrors our commitment to the men and women of the armed forces, take time to learn more about the career paths available here. It’s a genuine opportunity to do your life’s best work.

Diversity creates a healthier atmosphere: equal opportunity employer M/F/D/V

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, or national origin.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing.