About The Role

Job Title:Registered Nurse - Utilization Management (RN-UM)

Colorado Military Health System (CMHS), Fort Carson, CO, 80913

Graduate of an accredited school of nursing (BSN preferred).

Current, full, active, unrestricted RN license in a U.S. jurisdiction; BLS certification required.

Must be a U.S. Citizen; excellent analytical, communication, and organizational skills.

Updated Resume (With all gaps explained)
Current, full, active, unrestricted license as a Registered Nurse in any U.S. state or territory.
Basic Life Support (BLS) certification.

Conduct utilization management reviews to ensure healthcare services are medically necessary, appropriate, and cost-effective.
Act as a liaison with providers, referral centers, and TRICARE contractors to ensure patients receive care at the appropriate level and location.
Apply clinical knowledge to review medical necessities for specialty referrals, inpatient admissions, and outpatient services.
Prepare and analyze reports on utilization data and healthcare trends to identify inefficiencies or over/under-utilization.
Identify high-cost or complex cases, collaborating with case managers and providers to optimize patient care planning.
Ensure patient care complies with TRICARE access-to-care standards and DHA utilization policies.
Educate providers and staff on referral management processes and utilization criteria.
Support process improvement initiatives to enhance referral and utilization management across the CMHS.
Maintain accurate documentation of all utilization management activities in EHR systems.
Protect patient confidentiality and comply with HIPAA and DoD privacy requirements.

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