Summary This is a USPHS position within DHS, ICE, ERO, IHSC, Office of Deputy Assistant Director for Healthcare Compliance, Office of Health Plan Management. The Senior Utilization Review Consultant will report directly to the IHSC Regional Utilization Manager with the Utilization Management Program Administrator. This is a non-supervisory position. This position is only open to USPHS officers who are currently IHSC employees USPHS Call to Active Duty (CAD) candidates are not eligible for this position Responsibilities DUTIES AND RESPONSIBILITIES: Serves in the capacity of Senior Utilization Review Consultant and subject matter expert in program activities and policies related to utilization review and management. Must be able to perform tasks requiring independence with flexibility to adapt to variations of circumstance and approach with excellent judgment skills noting impact of error can cause impairment at department and program levels. Duties include day to day management of utilization review workload and related processes for prospective, concurrent and retrospective reviews and prevention of fraud, waste, and abuse and include but are not limited to: a. Record Management b. Resolution of complex and time sensitive utilization related issues c. Collection, review, tracking, and reporting of UM related data on a local, regional, and national level. d. Appropriately refers cases for high level of review and participates in Utilization Management Review Committee activities as needed. Incumbent reviews and provides input as requested on utilization management related contracts, policy, guides, framework, and program operations. Incumbent ensures compliance with program regulations (e.g., appropriateness of health care and services based on regulatory, reimbursement requirements, evidence-based national care guidelines and evidence-based practices), maintains records per program policy, participates in meetings and program or collateral duties as assigned, and communicates and collaborates with individuals or groups from outside the agency, including consultants and contractors. Incumbent functions as a mentor, preceptor, to other utilization review consultants (URC) and as a subject matter expert (SME) to internal/external stakeholders, referral coordinators and clerical employees regarding Medical Payment Authorization Requests (MedPARs) for select reimbursable health care services, medical claims review, and utilization review. Provides coverage for other Utilization Review Consultants (URCs), and RUM if required, during TDY and leave absences. Judgmental failure can result in ineffective or inappropriate use of resources and delays in meeting public health objectives of the office or agency. This may also impair the development of systems, affect the work of other staff, and compromise the delivery of other administrative and personnel services. Liaise with applicable internal and external stakeholders (e.g., Customs and Border Patrol, Veterans Affairs) regarding utilization management (UM) processes, trainings, and principles to ensure inpatient stays are within DRG limitations and, or extended length of stays as appropriate per national evidenced based guidelines. Provides orientation and guidance to the respective ICE, custody, and medical staff members of facilities in which ICE detainees are held regarding ICE policies, reporting requirements, and applicable ICE detention standards. The incumbent plans and organizes his/her own work within the UMP framework relative to role, is able to prioritize and determine the sequence of assignments, selects and develops methods conducive to program objectives, and rarely requires assistance. Assignments are usually long-term, recurring, or broadly defined. Work is reviewed for feasibility, compatibility with other work, program/regulatory compliance, and effectiveness in meeting requirements or expected program results. Travel may be required - estimated 15%. Travels TDY as needed to provide clinical care support at IHSC-staffed detention facilities with critical staffing needs. Performs other duties and responsibilities as assigned. Requirements Conditions of Employment Qualifications COMPETENCIES: Strong oral/written communication skills. Analytical Skills and ability to navigate complex systems. Strong interpersonal and active listening skills. Strong organizational and time management skills. Demonstrates strong problem solving, judgment and decision-making skills. Demonstrates integrity/honesty and cultural competency. Demonstrates leadership and supervisory skills. PHYSICAL DEMANDS: Required to walk unaided at a normal pace for up to 5 minutes and maintain balance. Required to jog/fast walk up to ¼ mile. Required to perform CPR/emergency care standing or kneeling. Must have the ability to assist sick, injured, or aging detainees or staff exiting the building (may require lifting, dragging, wheeling, or carrying someone who weighs significantly more than oneself). Sitting and/or standing for extended periods of time [6-8 Hours]. Performing repeated bending motion. Average manual dexterity for computer operation. Phone use for extended periods of time. Education REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES: Incumbent must possess a minimum of five years of professional experience relevant to the officer's category. Of the total professional experience, at least two years of experience must be related to management, administration, or evaluation of public health programs. Healthcare management or utilization management is preferred. Meet the minimum education requirements for either a nurse, nurse practitioner, or physician assistant Nurse. Must possess a qualifying bachelor's degree in nursing or a master's degree in nursing (with no qualifying bachelor's degree) accredited by the National League for Nursing Accrediting Commission (NLNAC) or the Commission on Collegiate Nursing Education (CCNE). Master's degree is preferred. Nurse practitioner. Must possess a certified advance practice nurse practitioner degree from a graduate school training program approved for this qualifying degree. Physician assistant. Must possess an accredited bachelor's, or master's degree, and completed a physician assistant training program accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) and have a national certification through the National Commission on Certification of Physician Assistants (NCCPA). Master's degree is preferred. Incumbent must possess at a minimum an industry certification related to billing, coding, and utilization/case management [e.g., MCG Care Guideline Specialist, Certified Professional Medical Auditor (CPMA), or Certified Inpatient Coder (CIC)] or must obtain within 12 months of hire. If the incumbent holds a clinical license, it is the responsibility of the incumbent to fulfill the obligation(s) of their licensing or certifying body to maintain current status. The agency may require the incumbent performs clinical activities with the scope of clinical license in times of critical needs within the agency. If in a clinical discipline and as directed and approved by his/her supervisors, the incumbent may perform clinical duties of their profession in Federal health care facilities. Such direction is documented via a memorandum of assignment and is filed in the eOPF. Possesses well-developed knowledge and skills in the areas of utilization management (and/or case management) and medical necessity. Has knowledge of medical, administrative, ethical, and legal requirements and standards related to healthcare delivery. Currently has or can achieve and maintain utilization management or other applicable certification as directed by IHSC through formal training and other means. Should possess some knowledge of International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10), current procedural terminology (CPT), diagnosis-related group (DRG), and other Centers for Medicare and Medicaid Services (CMS) coding/billing requirements. Ability to critically analyze situations, data and information, and be able to develop and pose probing questions, identify problems, and make recommendations towards their resolution. Maintains clinical professional skills via continuing education opportunities. Maintains CPR/BLS certification. Professional background in health care with extensive direct patient care experience, preferably within a correctional setting. Computer literate on Adobe and MS Office applications. Additional Information The HPMU Utilization Management Program (UMP) is a national level program and is essential for ICE detainee healthcare and the ICE/IHSC/HPMU mission. HPMU UMP collaborates with the Veterans Affairs Financial Services Center (VAFSC), a third-party medical claims administrator, and offsite providers to establish letters of understanding with IHSC. HPMU UMP also works jointly with IHSC stakeholders: pharmacy; dental; the Behavioral Health Unit; the Medical Case Management Unit; and IHSC headquarters to meet mission initiatives. HPMU UMP trains referral coordinators to improve processes related to claims process workflows to decrease claims denials and increase the number of paid claims. UMP staff will adopt and use the MCG Care Guidelines to ensure compliance with program standards/regulations (e.g., appropriateness of health care and services based on regulatory, reimbursement requirements, evidence-based national care guidelines and evidence-based practices), maintains records per program policy, chairs meetings, coordinates and manages programs within immediate organizational component. UMP communicates and collaborates with individuals or groups from outside the agency, including consultants and contractors. IHSC has a multi-sector, multidisciplinary workforce of more than 1400 employees, including U.S. Public Health Service (PHS) commissioned officers, federal civil servants, and contract staff. IHSC provides on-site direct patient care to ICE detainees at 19 detention facilities throughout the country and manages the provision of off-site medical care for detainees housed in approximately163 additional non-IHSC-staffed facilities, with a combined population of 34,000 detainees daily, with an average length of stay of about 30 days, and over 400,000 detainees transitioning through these facilities annually. IHSC also provides medical support during ICE enforcement operations in the air, on the ground and at sea. SUPERVISORY CONTROLS: The Senior URC reports directly to the assigned IHSC Regional Utilization Manager (RUM) with the Utilization Management Program Administrator (UMPA) as the reviewing official. This is a non-supervisory position. The Officer is responsible for performing highly specialized professional duties related to Utilization Management and Utilization Review. Assignments are usually of a long-term, recurring or broadly defined nature. Officer plans, and organizes own work, determines sequence of assignments, selects and develops methods and seeks assistance from experts only rarely. Work is reviewed for attainment of objectives. Guidelines may be applicable to some but not all parts of assignment and may contain some inconsistencies and be partially unconfirmed. Selection and adaptation from available possibilities involving a moderate amount of modification and innovation is required. The officer uses judgment in interpreting and adapting guidelines such as PHS policies, regulations, precedents and work direction for application to specific cases. The officer analyzes results and recommends changes in guidelines and program policies. Innovations and modifications to accepted procedures must be approved and clearly documented. The officer keeps the supervisor informed of the status on projects and consults with him/her on any significant problems encountered.