Attch1_PWS_Utilization_Mgr.pdf

Performance Work Statement (PWS) Utilization Manager

PERSONAL SERVICES

1.0 REQUIREMENTS

1.1 This contract is awarded using the 10 USC 1091 authority for personal services. The contracted position creates an employer-employee relationship between the (herein Contractor) and government representative identified at the start of the contract period of performance.

1.2 The government requires one Full Time Equivalent for this PWS. The Contractor shall provide

Utilization Manager-type of care to treat and/or support the treatment of the patients of the 31st Medical Group, Aviano Medical Treatment Facility (MTF).

1.2.1 The MTF intends on the services, as identified in this PWS, to be performed by a qualified

Technical Representative (TR) and the contractor will conduct the TR work.

1.2.2 Performance shall be in accordance with the requirements contained in this document in addition to the professional standards of the Joint Commission, USAF Medical Services standards, and any local standards maintained by the unit.

2.0 DUTY HOURS

2.1 The Contractor will work no more than 40 hours per week. The Contractor shall be available Monday through Friday, 0730 until 1630 Central European Time (CET). The Contractor shall not work more than 8 hours per day.

2.2 The Contractor will not be required to work on, and be paid for, the following days:

2.2.1 New Year’s Day

2.2.2 Martin Luther King’s Birthday

2.2.3 Washington’s Birthday (President’s Day)

2.2.4 Memorial Day

2.2.5 Juneteenth Day

2.2.6 Independence Day

2.2.7 Labor Day

2.2.8 Columbus Day

2.2.9 Veterans Day

2.2.10 Thanksgiving Day

2.2.11 Christmas Day

2.2.12 USAFE Family Days

2.2.13 Any other military-sponsored Wing holiday

2.3 The Contractor’s lunch period shall be 60 minutes. This lunch period shall be coordinated with the government supervisor or Functional Requirements Evaluator Designee (FRED) to alleviate any scheduling conflicts.

2.4 For unusual and compelling circumstances (e.g., weather emergencies) in which the Commanding

Officer either excuses all facility personnel from reporting to work or dismisses all personnel early, the Contractor shall still accrue a normal day’s pay.

3.0 ABSENCES AND LEAVE

3.1 The Contractor is authorized up to 24 days of Paid Time off (PTO) within a contract year. The Contractor does not have access to this PTO until 30 days after the contractor has started performance.

PTO shall be used for both planned (vacation) and unplanned (sickness) absences. PTO must be used in the contract year in which it is accrued. PTO that is not used will be forfeited at the end of the contract year.

3.1.1 Limited to six days per quarter, based on the period of performance, unless authorized by the Commanding Officer.

3.2 Planned absences from assigned duties shall be requested with 15 working days advance notice, in writing, to the government Supervisor or FRED.

3.3 Family and Medical Leave. Upon request, up to 12 weeks of family or medical leave, may be granted to the Contractor if the circumstances specified in the Family and Medical Leave Act (FMLA), Sec. 102, apply.

3.3.1 If the family or medical leave is granted, all PTO days must be used; then, the remaining time off will be Leave without Pay (LWOP).

3.3.2 If the Contractor is absent for three or more consecutive days due to illness, he or she may be required by the government supervisor or FRED to provide written documentation from a qualified health care provider that he or she is free from communicable disease and the cause of the Contractor's current illness. The government reserves the right to examine and/or re-examine any Contractor who meets this criterion.

4.0 DUTIES AND RESPONSIBILITIES. The Contractor shall perform a full range of duties consistent with their labor category, education, training, experience, clinical privileges (as applicable) and assigned position.

4.1 Provides Utilization Management activities and functions by using MTF-specific Quality Improvement processes to identify areas for review based on data, suspected problem areas, and input from departments/services within the facility while collaborating with Medical Group (MDG) staff, facility departments, and outside agencies to determine the best, most cost-efficient care. Collaborates with staff/departments, including, but not limited to:

4.1.1 Executive Management

4.1.2 Resource Management

4.1.3 Medical Records

4.1.4 Patient Administration

4.1.5 Group Practice Managers

4.1.6 Health Care Integrator

4.1.7 Disease Management

4.1.8 Coders/Coding Auditors

4.1.9 Medical Management/Referral Management

4.1.10 TRICARE Operations

4.1.11 Patient Care teams

4.1.12 Quality Improvement

4.1.13 Safety Officer

4.1.14 Managed Care Support Contractors

4.2 Prioritizes accordingly based on high-dollar, high-volume or problem-prone diagnoses, while keeping abreast of MTF and local market services and capabilities & capacity.

4.3 Identifies gaps between desired and actual program outcomes and develops an action plan to fix gaps then determine effectiveness of the plan and continually evaluate the impact of implementation.

4.4 Incorporates applicable utilization review tasks to ensure patients receive the right care, at the right time, in the right place, with the right provider, at the right cost while routinely monitoring referral management Composite Health Care System (CHCS) queue to ensure patient’s referrals are appointed, followed up and administratively closed as appropriate. Conducts referral reconciliation report as directed, identifying all open referrals and provides notification to appropriate providers/PCMH teams to close the loop on unattended patient referral.

4.5 Must be able to perform prospective, concurrent, and retrospective reviews to justify medical necessity for requested medical care and to aid in collection and recovery from multiple insurance carriers.

4.6 Develops and implements a comprehensive Utilization Management plan/program in accordance with the facility's goals and strategic objectives.

4.7 Performs data/metrics collection on identified program areas; analyzes and trends results, including over and under-utilization of healthcare resources. Identifies areas for improvement and cost containment. Reports utilization patterns and provides feedback to SGH, clinical providers and medical management team in a timely manner.

4.8 Update the capability report as needed to guide providers in placing in-house referrals to visiting specialty care providers.

4.9 Analyzes medical referrals/appointments and general hospital procedures and regulations by monitoring specialty care referrals for appropriateness, covered benefits, and authorized surgery/medical procedures as indicated.

4.10 Monitors active duty and active duty beneficiary admissions and discharges to and from civilian hospitals to ensure appropriateness and identify re-capture of care opportunities as indicated.

4.11 Participates in customer service initiatives, performance, safety and quality improvement measures and medical readiness activities designed to enhance health services while proactively identifying process issues that could lead to negative patient outcomes and participates in the appropriate safety reporting processes for the facility.

4.12 Must maintain a level of productivity and quality consistent with:

4.12.1 complexity of the assignment

4.12.2 facility policies and guidelines

4.12.3 established principles

4.12.4 ethics and standards of practice of professional nursing

4.12.5 the Case Management Society of America (CMSA)

4.12.6 American Accreditation Healthcare Commission/Utilization Review

4.12.7 Accreditation Commission (URAC)

4.12.8 Comprehensive Accreditation Manual for Hospitals (CAMH)

4.12.9 The Joint Commission (TJC)

4.12.10 Other applicable DoD and Service specific guidance and policies

4.13 Completes medical record documentation and coding, and designated tracking logs and data reporting as required by local MTF/AF/DoD instructions, policies and guidance.

5.0 EDUCATION AND TRAINING REQUIREMENTS

5.1 Formal Education. The Contractor must meet all minimum education requirements for Utilization Managers.

5.1.1 Must hold a Bachelor's of Science Degree in Nursing from a fully accredited School of Nursing. A Master's Degree is highly desired, but not mandatory.

5.2 Experience. The Contractor is required to have 12 months of full-time experience in the last 36 months.

5.3 Knowledge. The Contractor must possess and demonstrate familiarity with one of the following:

5.3.1 Ambulatory Procedure Grouping (APGs)

5.3.2 Diagnostic Related Grouping (DRGs)

5.3.3 International Classification of Diseases-Current Version (ICD)

5.3.4 Current Procedural Terminology-Current Version (CPT) coding

5.3.5 McKesson (InterQual) and/or Milliman Care Guidelines

5.4 A current Basic Life Support (BLS) certification is a job requirement.

6.0 Preferred Education and Training

6.1 Preferred Certifications:

6.1.1 American Board of Manager Care Nurses (AAMCN)

6.1.1.1 Certified Managed Care Nurse (CMCN)

6.1.2 American Nurses Credential Center (ANCC)

6.1.2.1 Informatics Nursing Certification (RN-BC).

6.1.2.2 Ambulatory Care Nursing Certification (AMB-BC)

6.1.2.3 Medical-Surgical Nursing Certification (MEDSURG-BC)

6.1.2.4 Nursing Case Management Certification (CMGT-BC)

6.2

7.0 ADDITIONAL QUALIFICATIONS

7.1 Language Requirement. The Contractor shall read, understand, speak, and write English fluently.

7.2 The Contractor must be knowledgeable in medical privacy and confidentiality (Health Insurance Portability and Accountability Act [HIPAA]); accreditation standards of Accreditation Association for Ambulatory Health Care (AAAHC) and The Joint Commission (TJC).

7.3 Computer applications/software to include Microsoft Office programs, MS Outlook (e-mail), and internet familiarity is required.

7.4 The ability to input, extract and format data from established databases is desired.

7.5 The Contractor must be skillful and tactful in communicating with people who may be physically or mentally ill, uncooperative, fearful, emotionally distraught, and occasionally dangerous.

7.6 The Contractor must possess organization, problem-solving and communication skills to articulate medical requirements to patients, families/caregivers, medical and non-medical staff in a professional and courteous way.

8.0 FAILURE AND/OR INABILITY TO PERFORM

8.1 This contract may be terminated if the Contractor fails to provide any requested certifications in accordance with this PWS, or if clinical privileges are not granted to the Contractor at the discretion of the Commanding Officer.

8.2 Should the Contractor be unable to perform duties under this contract due to medical or physical disability for more than 13 consecutive days, performance under this contract may be suspended by the Contracting Officer until such medical or physical disability is resolved. If performance under this contract is so suspended, no reimbursement shall be made and no other compensation, including annual/sick leave, shall accrue to the Contractor so long as performance is suspended.

8.3 Any Contractor demonstrating impaired judgment, shall be removed from providing health care services. The government reserves the right to remove any Contractor who, in the judgment of a licensed physician, is impaired by drugs, alcohol, or physical illness. The Contractor may be allowed to return to work under the terms of this contract only with prior government approval.

8.4 If the Contractor is required to leave Italy and can no longer perform the required services, a notification must be provided to the Contracting Officer as early as possible, but at a minimum two weeks from the final day of service.

8.5 The Contractor must obtain permission from MDG/CC or Clinic Administrator (SGA) before competing on a different contracted position while employed under this contract. If permission is denied, the Contractor is not allowed to resign their position without consequence of Termination for Cause.

9.0 HEALTH REQUIREMENTS

9.1 Not later than five (5) working days prior to commencement of work, the Contractor shall furnish a completed Public Health MEHP In-Processing Questionnaire to the Government Supervisor or FRED.

9.2 Occupational Safety and Health Administration (OSHA) requires that all Health Care Workers who will have occupational exposure to blood or body fluids, or other potentially infectious materials, shall receive Hepatitis B vaccine, sign a voluntary declination, or have documented proof of immunity to Hepatitis B infection. Personnel who sign declinations may change their minds at any time and receive the Hepatitis B vaccine without penalty.

9.3 The MTF will provide emergency health care to the Contractor for injuries incurred while on duty in the MTF. These services will be billed to the Contractor at the current full reimbursement rate.

10.0 GENERAL INFORMATION

10.1 Orientation. The Contractor shall participate in the MTF orientation briefing/training for newly assigned personnel to include regulations specific to their professional specialty, clinic and Air Force policy and procedures.

10.2 In-processing and out-processing. In compliance with local standards, the Contractor must complete in-/out-processing actions within 45 days.

10.2.1 Failure to do so promptly may delay payment of the first and final invoices.

10.3 Security. The Contractor shall provide all pass and identification items required for contract performance. The Contractor shall return all identification media to the Pass & ID office upon completion/termination of the contract, as appropriate.

10.4 Common Access Card (CAC). The Contractor will be required to receive a CAC while performing under this contract. Failure or inability to receive a CAC will result in contract termination.

10.5 National Agency Check (NAC). As a minimum, the Contractor shall successfully complete a NAC before operating government-furnished workstations that have access to Air Force automated information systems. Contractors receiving unfavorable NACs shall not be employed.

10.5.1 The government will submit requests for investigations on AF Form 2583, “Request for

Personnel Security Action”, or local equivalent at no additional cost to the Contractor.

10.6 Credentials. The Contractors will be subject to the credentialing and privileging requirements of AFI 44-119, to include adverse actions as applicable.

10.6.1 If applicable, credentials will be verified by the MTF before contractor performance begins.

10.6.2 The Contractor will maintain applicable licensure and certifications at no additional cost to the government.

10.7 Physical Security. The Contractor shall safeguard all government property, including controlled forms provided for use. At the close of each work period, government equipment, facilities, and other valuable materials shall be secured.

10.8 Entry Procedures to Controlled/Restricted Areas. The Contractor shall comply with local base procedures for entry to Air Force controlled/restricted areas where Contractor will work.

10.9 Key Control. The Contractor shall ensure keys issued by the government are properly safeguarded and only used by authorized personnel.

10.9.1 The Contractor shall use keys to open work areas for authorized staff engaged in performance of their duties. Lost keys shall be reported immediately to the assigned Flight Commander or his/her designee.

10.9.2 The government will replace lost keys or perform re-keying at the expense of the Contractor, which will be deducted from their monthly payment.

10.10 HIPAA. In accordance with DoD 6025.18-R “Department of Defense Health Information Privacy Regulation,” 24 January 2003, the Contractor meets the definition of Business Associate. Therefore, a Business Associate Agreement is required to comply with both the Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security regulations regarding health information as defined in this clause, DoD 6025-18-R, DOD 8520.02-R and AFI 41-217. Additional requirements will be addressed when implemented.

10.11 PHI. In accordance with 45 CFR 164.502, the Contractor agrees to use all appropriate safeguards to maintain integrity of Protected Health Information (PHI) and prevent use or disclosure other than as provided by this contract. The Contractor will report awareness of PHI security incidents to the government.

11.0 Services Summary

PERFORMANCE

OBJECTIVES

PWS

Paragraph

Performance Threshold Remedies

SS-1) Complies with safety policies

1.2.2 Zero violations are

standard (Can exceed by actively preventing violations).

Remedial training will be provided to the contractor.

SS-2) Hygiene and grooming meet hospital standards.

2.1

No more than 3 valid customer complaints.

If more than 3 valid customer complaints are received, the CO will meet with contractor to explain what is expected when referring to hygiene and grooming in a hospital environment.

SS-3) Maintains professional manners and displays

1.2.2 No more than 3 valid

customer complaints.

If more than 3 valid customer complaints are received, the CO, along with 31 MDG, will meet with contractor to explain what professional manner and displays are expected when dealing with patients.

SS-4) Available for work at the appointed times.

2.1 No more than 3 instances

of tardiness or leaving early in a quarter

If more than 3 instances of tardiness or leaving early in a quarter are reported, the CO will calculate the percentage to be deducted on the monthly fee.

SS-5) Adheres to work duties and schedule for shifts other than normal duties hours as required

2 No unplanned absences are authorized.

If a valid unplanned absence is reported, the CO will calculate the percentage to be deducted on the monthly fee and it will be reported to the 31 MDG Commander, or designee or Mission Owner. Any required actions to be taken will be determined by the CO.

SS-6) Annual trainings

4.11 Individuals must complete

all trainings required on time.

Annual computer-based trainings (CBT) will be completed by deadlines in order to perform required duties.

SS-7) Work competency 4.4, 4.9 No more than 3 valid customer complaints.

If more than 3 occurrences are reported, FRED will give remedial training and will mark performances as unsatisfactory.

SS-8) Completes all in-processing and out- processing within 31 MDG requirements

10.2 The individual must

complete in-/out-processing within 45 days.

31 MDG will not allow individuals to perform required duties until in-processing is complete.

12.0 APPLICABLE PUBLICATIONS AND FORMS.

12.1 Publications and forms applicable to the performance of work statement (PWS) are listed below.

12.2 The Contractor is obligated to follow those publications. These publications are available in the MTF and maintained by the government.

12.3 Supplements or amendments to listed publications from any organizational level may be issued during the life of the contract.

12.3.1 The Contractor shall immediately implement those changes in publications.

12.3.2 For changes in publications which result in a price change.

12.3.2.1 Prior to implementing any change the Contractor shall provide a proposal for increase or decrease in the price to the CO within 30 days of receipt of the change by the Contractor.

12.3.2.2 The CO and the Contractor shall negotiate the change into the contract under the provisions of the contract clause entitled "Changes".

12.4 Publications and forms are also available electronically through the internet. For example, https://www.e-publishing.af.mil/ is the Air Force's e-Publishing site and one way to obtain Air Force Instructions. DoD Directives can be found at https://www.esd.whs.mil/DD/.

PUB NO. TITLE

DEPARTMENT OF DEFENSE REGULATIONS/ MANUALS/ INSTRUCTIONS/ DIRECTIVES

DoDD 5200.2 Personnel Security Program DoDD 5400.11 Privacy Program DoD 5400-07 DoD Freedom of Information Act Program DoDD 5500.7 Standards of Conduct DoD 6025.18 HIPAA Privacy Rule Compliance in DoD Health Care Programs DoDD 8500.1 Cybersecurity DoDI 1402.5 Criminal History Background Checks in individuals in Child Care Services DoDI 1100.22 Policy and Procedures for Determining Workforce Mix

AIR FORCE INSTRUCTIONS/MANUALS

AFI 16-1404 Air Force Information Security Program AFI 31-501 Personal Security Program Management AFI 33-322 Records Management and Information Governance Program AFI 44-102 Medical Care Management AFI 44-119 Medical Quality Operations AFI 48-104 Tobacco Free Living AFI 71-101V1 Criminal Investigations AFMAN 33-152 User Responsibilities and Guidance for Information Systems AFMAN 33-202 Freedom of Information Act Program

SS-9) Maintains patient privacy/confidentiality

7.2, 10.10, 10.11

Standard is zero breaches of privacy (May exceed by actively preventing violations).

If there is a breach in patient privacy/confidentiality, the CO, along with the 31 MDG Commander will determine what actions to be taken on a case by case determination.

SS-10) Adheres to all HIPAA requirements

7.2, 10.10, 10.11

Standard is zero breaches of HIPAA requirements.

Every time the Contractor breaches the HIPAA requirements it will be reported to the 31 MDG Commander, or designee or Mission Owner. Any required actions to be taken will be determined by the CO, along with 31 MDG Commander or designee.

https://www.esd.whs.mil/DD/

AFMAN 33-363 Management of Records AFMAN 48-105 Public Health Surveillance

FORMS

DD Form 1172 Application for Uniformed Services Identification Card Standard Form 86 Questionnaire for National Security Positions FD Form 258 FFBI US Department of Justice Fingerprint Card