Registered Nurse – Utilization Management

Job ID: 11866

Posted: 9 Days Ago

Base: Naval Hospital - Pensacola

FLSA: Hourly Non-Exempt

Job Type: Permanent

Location: Florida (FL)

Gross Pay: $34.81


"We encourage Military Veterans and Military Spouses to apply"



  The contractor shall provide personnel for service at the Naval Hospital Pensacola, FL.



·       Degree: Associates Degree of Nursing.

·       Education:

  Graduation from an accredited nursing educational program

·       Experience:

   One year of experience in nursing as identified in the TO after graduation.

·       Licensure: Possess and maintain a current unrestricted license to practice as an RN in any one of the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, Guam or the U.S. Virgin Islands.

·       Certification: Possess current certification in ONE (1) OF THE FOLLOWING:

  Certified Professional Utilization Review (CPUR) from McKesson Health Solutions.

  Certified Professional Utilization Management (CPUM) from McKesson Health Solutions.

  Health Care Quality and Management Certification from American Board of Quality Assurance and Utilization Review Physicians (ABQAURP).

  Certified Professional in Healthcare Quality (CPHQ) from Healthcare Quality Certification Board (HQCB).

  Certified Case Manager (CCM) issued by the Commission for Case Manager Certification.

  Advanced Certification in Continuity of Care (ACCC) issued by the National Board for Certification in Continuity of Care.

  Nurse Case Manager (RN-NCM) issued by the American Nurses Credentialing Center.

  Care Manager Certified (CMC) issued by the National Academy of Certified Care Managers.


  Possess two (2) years of full-time broad based registered nurse experience in a utilization management review or a case management setting within the preceding five (5) years. Notwithstanding the aforementioned experience requirements, the HCWs must have pertinent clinical experience within the past two (2) years sufficient to demonstrate current clinical competency for the setting and procedures required by this contract.

·       Additional Certificate: BLS Basic Life Support, through the American Hear Association

·       U.S. Citizenship: HCWs performing under this contract shall be U.S. citizens.

·       Able to read, write, and speak English well enough to effectively communicate.

·       Shall be physically capable of standing and/or sitting for extended periods of time and physically capable of performing all services required.


o  Provide two (2) letters of recommendation written within the last two (2) years attesting to his/her current clinical competency and the clinical responsibilities (setting and patients).

o  A minimum of one (1) of the letters must be from a clinical supervisor. 

o  The other letter must be from a clinical peer. 

  Reference letters shall attest to the quality and quantity of experience including, but not limited to, the communication skills between nurse and patient and among peers, and must include name, title, and phone number, date of reference, address, and signature of the individual providing reference.


·       Assist in the design and implementation of activities to increase hospital staff involvement in and support of an active and coordinated Medical Management program. As a member of the Medical Management team, the HCW shall work in coordination with Case Management, Disease Management, Referral Management, and other members of the healthcare team in order to assure the seamless delivery of care. All services shall be provided in accordance with Military Treatment Facility (MTF) policies and protocols.

·       Incorporate utilization review activities using the generally accepted standards and criteria for determining medical necessity, appropriateness, and reasonableness when reviewing the quality, completeness, and adequacy of health care provided to individual patients and patient populations and subsequently with similar patient populations. The HCW shall:

·       Promote collaboration and communication among all Medical Management staff, including clinical and business personnel, to promote efficient, effective, and high-quality care and services.

·       Seek to reduce overutilization of Emergency Department (ED) or high-cost medical settings by identifying patients with chronic diseases (e.g., diabetes, asthma, etc.) that have a significant impact on healthcare outcomes and costs.

·        Participate in a progressively integrated approach to provision of services in coordination with Case Management and Disease Management. This approach shall emphasize the importance of facilitating environments, treatments, and procedures that generate opportunities for improved clinical outcomes and/or cost avoidance on both the individual and patient population level.

·       Participate in the development of a utilization management monitoring process that provides the MTF with a “warning system” that can help identify at-risk patients (e.g., patients with diabetes, asthma, other chronic conditions, etc.) at the earliest opportunity for intervention, such as during the preadmission and concurrent review processes. For example, patients with specific diseases/ conditions scheduled for admission to the hospital can be identified and referred as potential candidates for Case Management or Disease Management services. As necessary, facilitate proactive discharge planning to help address such patients’ post-hospitalization needs.

·       Similarly, ensure patients with conditions entailing polypharmacy interventions (e.g., when the patient has been prescribed seven or eight concurrent medications), unexpected admissions, etc., receive appropriate follow up monitoring.

·       Coordinate with multidisciplinary teams to meet the health care needs, including medical and/or psychosocial management of specific patients, and subsequently, similar patient populations.

·       Alert physicians to significant changes or abnormalities in patients and provide relevant information concerning their condition, medical history and specialized treatment plan or protocol.

·       Interface with interdisciplinary teams associated with utilization management activities and serve as a consultant to all disciplines regarding utilization management and related issues.

·       Provide nursing expertise about utilization management, including assessment, planning, implementation, coordination, and monitoring.

·       Maintain current knowledge of utilization screening criteria, including but not limited to Milliman, InterQual, Tricare Manual, Medicare benefit manual. Maintain departmental databases and compile statistics from utilization management tracking studies

·       Ensure adherence to Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Utilization Review Accreditation Commission (URAC), Case Management Society of America (CMSA) and other regulatory requirements.

·       Provide continual tracking and monitoring of beneficiaries hospitalized in network and non-network facilities and suggests opportunities to recapture care within multiservice market to Director and assists team in providing smooth transition of care.

·       Create daily and periodic reports for Director of Healthcare Business Operations regarding beneficiaries hospitalized in network and non-network facilities.

·       Serve as a liaison with Managed Care Support Contractor (MCSC) for utilization management-related issues.

·       Provide assistance in ensuring utilization management compliance with MCSC contractual agreements.

·       Utilize the results of utilization studies/reviews and individual cases to recommend changes to policy, procedures, or protocol documentation.

·       Establish cost containment/cost avoidance strategies for utilization management and develop mechanisms to measure its cost effectiveness.

·       Participate in the selection of topics for Utilization Management focus reviews and development of utilization management studies.

·       Update utilization management procedures based on latest government or local MTF policies

·       Provide professional presentations as requested/required.

·       Develop mechanisms to evaluate patient, family and provider satisfaction and use of resources/services.

·       Serve as a primary contact person for utilization management in a multiservice environment.


·       Maintain a level of productivity comparable with that of other individuals performing similar services.

·       Participate in peer review and performance improvement activities.

·       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.

·       Perform efficiently in emergency patient situations following established protocols, remaining calm, informing appropriate persons, and documenting events. Anticipate potential problems/emergencies and make appropriate interventions. Notify supervisor, director, or other designated person regarding problems that the HCW is unable to manage.

·       Apply an awareness of legal issues in all aspects of patient care and strive to manage situations in a reduced risk manner.

·       Participate in the implementation of the Family Advocacy Program as directed. Participation shall include, but not be limited to, appropriate medical examination, documentation, and reporting.

·       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.

·       Participate in continuing education to meet own professional growth.

·       Attend and/or comply with all annual training classes required by the Command, to include but not limited to online annual training provided by the MTF: disaster training, infection control, Sexual Harassment, Bloodborne Pathogens, Fire and Safety, Chemical, Biological, Radiological, Nuclear and Explosives (CBRNE), and all other required training.

·       Actively participate in the command’s Performance Improvement Program. Participate in meetings to review and evaluate the care provided to patients, identify opportunities to improve the care delivered, and recommend corrective action when problems exist.

·       Participate in the provision of in-service training to clinic staff members. Provide training and/or direction as applicable to supporting government employe­es (e.g., hospital corpsmen, students, etc.).

·       Attend and participate in various meetings as directed.

·       Perform timely, accurate, and concise documentation of patient care.

·       Operate and manipulate automated systems such as CHCS, AHLTA, ADS, Essentris, MHS Genesis and Clinical Information System (CIS), participate in clinical staff Performance Improvement (PI) and Risk Management (RM) functions, as prescribed by the Commander. Maintain DOD email account as directed. The HCW shall be responsive to all email and voicemail communications.

·       Exercise appropriate delegation of tasks and duties in the direction and coordination of health care team members, patient care, and clinic activities.

·       Maintain documentation of all treatment provided in accordance with clinic directives and prepare such records and reports as may be required. All records and reports must be legible. Abbreviations must be only those listed in local instructions.

·       Participate in all phases of the Case Management Program (CMP) and ensure that the CMP meets established case management (CM) standards of care.

·       Provide nursing expertise about the CM process, including assessment, planning, implementation, coordination, and monitoring. Identify opportunities for CM and identify and integrate local CM processes.

·       Develop and implement local strategies using inpatient, outpatient, onsite and telephonic CM

·       Develop and implement tools to support case management, such as those used for patient identification and patient assessment, clinical practice guidelines, algorithms, CM software, and databases for community resources

·       Integrate CM and utilization management (UM) and integrating nursing case management with social work case management

·       Maintain liaison with appropriate community agencies and organizations

·       Accurately collect and document patient care data.

·       Develop treatment plans including preventive, therapeutic, rehabilitative, psychosocial, and clinical interventions to ensure continuity of care toward the goal of optimal wellness

·       Establish mechanisms to ensure proper implementation of patient treatment plan and follow-up post discharge in ambulatory and community health care settings

·       Provide appropriate health care instruction to patient and/or caregivers based on identified learning needs.


·       Services shall normally be provided Monday through Friday between the hours of 0630 and 1800, for an eight and a half (8.5) or nine (9) hour shift, including a 30 minute or one (1) hour uncompensated meal break.

·       Services will normally not be required on the day of observance of Federal holidays.

·       The HCWs shall each be on duty for about 80 hours every two (2) weeks, except during periods of approved leave and holidays.

·       The department head of Utilization Management and Family Medicine/Internal Medicine may periodically adjust the daily work schedule as needed working within the confines of 80 hours in a two (2) week period.


Must be comfortable in a fast-paced, dynamic environment. Must be able and willing to reprioritize on short notice and work on multiple simultaneous projects. Flexible and able to work with various personalities. Teamwork skills required. Time management skills required. The ability to meet deadlines in a deadline intensive environment is essential. High level of adaptability and willingness to embrace change in a fast-paced, demanding environment.


LUKE does not discriminate on the basis of race, sex, color, religion, national origin, age, disability, or veteran status in provision of services or employment opportunities and benefits. 

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


To learn more about Luke, please visit our website at:

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Why choose LUKE?

At LUKE, we’re honored the U.S. Government has entrusted us with their staffing needs for over 20 years. We’ve built a strong reputation as a reliable partner, delivering vital healthcare solutions.

When you join our team, you become part of a nationwide network of top-tier professionals who share your passion for excellence. Whether you’re a nurse, physician, therapist, caregiver, or any other healthcare specialist, we have a diverse range of positions available to match your unique skills and interests.