Manager Utilization Management Jobs in Bothell, WA

Arcetyp LLC is a growing small business that provides a broad range of consulting services to US Federal Government, US Military, and Commercial clients. Services include Management & IT Consulting, Program & Project Management, and Professional & Admin Services.

We accept direct hire candidates only, W2 employee hires. We do not accept 1099 independent consultants. We do not accept staffing firms. We do not accept corp-to-corp (C2C) candidates. We can't sponsor H1B.

Arcetyp LLC is looking for a Pharmacy Technician to support the Government in Japan. This will be an on-site, in-office position with one position located in Iwakuni, Japan.

POSITION DUTIES:

• The Pharmacy Technician will assist in developing and refi ning referral management (RM) to support medical management initiatives at the military treatment facility (MTF).

ESSENTIAL JOB FUNCTIONS

• Assess, monitor and evaluate and assist in processing referrals for authorization. The contractor shall
  review specialty care referrals for clinical appropriateness, covered benefit, and administrative and
  medical completeness following MTF, DHA, BUMED guidelines and TRICARE policy.
• The HCW shall input and retrieve patient information for each referral, through the use of various
  computer systems include Electronic Health Record (EHR), 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 one business days. Timelines shall be monitored through
  computer reporting systems such as Electronic Health Record and TRICARE Reports.
• Elevate referrals to the medical manager, utilization nurse, 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 regard to preauthorization.
• Submit monthly, quarterly, and yearly utilization reports using Electronic Health Record 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 ten 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, DHA policies, BUMED Referral Management
  Guidelines; Referral Management policies; TRICARE policies and procedures; and ICD and DRG codes.
• 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 approved tools and
  electronic health record. 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,
  TRICARE, and DHA policies.
• Provide education and training on the referral management process, specialty referral guidelines, and
  related policies to beneficiaries, providers, and host nation partners.

NECESSARY SKILLS AND KNOWLEDGE:

• 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.
• Each HCW providing service under this contract or resultant task orders shall 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.

MINIMUM QUALIFICATIONS:

• Possess and maintain a current certification and registration by the Pharmacy Technician Certification
  Board (PTCB).
• HCW shall be in good standing, and under no restrictions, with the state licensure board in any state
  in which a license is held or has been held within the last 10 years.
• HCW shall be in good standing and under no sanction or suspension by the Federal Government.
• Possess and maintain current certification in either the American Heart Association BLS for Healthcare
• Providers or American Heart Association Healthcare Provider Course.
• Able to read, write, speak, and understand the English language fluently and maintain good
  communication skills with patients and other health care personnel.
• Ability to pass all background/suitability checks.
• A valid driver's license and ability to travel locally as needed.
• Ability to work some night, weekend, and holiday shifts.

PREFERRED QUALIFICATIONS:

• 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.

Min. Citizenship Status Required: U.S Citizenship.

LOCATION: Iwakuni, Japan

COMPENSATION: Pay and benefits information for this position will be provided to interested candidates that apply. Arcetyp offers a package of compensation and benefits to full-time salaried employees.

Arcetyp is an Equal Opportunity Employer and we highly value diversity of our workforce. We accept resumes from all interested parties and consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital status, sexual preference, personal appearance, family responsibility, the presence of a non-job-related medical condition or physical disability, matriculation, political affiliation, veteran status, or any other legally protected status.