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Role Description

Responsible for application of appropriate medical necessity tools to maintain compliance and achieve cost effective and positive patient outcomes.

• Acts as a resource to other team members including UR Tech and AA to support UR and revenue cycle process.

Position Responsibilities

• Utilization Management
  • Utilizes Payer specific screening tools as a resource to assist in the determination process regarding level of service and medical necessity.
  • Consults with Physician Advisor to discuss medical necessity, length of stay, and appropriateness of care issues.
  • Identify and manage concurrent and retroactive denials through communication with attending physicians, case management, multidisciplinary team, external physician resource group and payers.
• Documentation
  • Appropriate and complete documentation of clinical review and denial management in the case management documentation system and in the billing system.
• Denial Management
  • Manages the concurrent denial process by referring to appropriate resource for concurrent and retrospective appeal activity process.
  • Prepares and facilitates audits using appropriate screening tools and documentation.
• Metrics
  • Accountable to job specific goals, objectives and dashboards which contribute to the success of the organization.
  • Participates in organizational improvement activities including patient satisfaction, Six Sigma committee, department and/or divisional teams and community activities.
• Compliance
  • Understands and applies applicable federal and state requirement.
  • Identify and reports compliance issues as appropriate.

Qualifications

• RN required.
• 3 years clinical nursing (RN) experience and 1 year UR/CM/QM experience preferred.
• Basic understanding of Medicare, Medicaid and managed care.
• Discharge planning or home health background.
• Excellent verbal and written communication skills, problem solving, critical thinking and conflict resolution.

Required Education

• Graduate of an accredited School of Nursing, BSN strongly preferred.

Training/Certifications/Licensure

• Licensure from the State of New Jersey as a Registered Nurse.
• Case Management Certification (requirement within one year of hire beginning April 1, 2015).

Annual Salary

$77,405 - $123,574. The actual salary/rate will vary based on applicant’s experience as well as internal equity and alignment with market data.

Benefits

• Medical/prescription, dental and vision insurance.
• Health and dependent care flexible spending accounts.
• 403(b) (401(k) subject to collective bargaining agreement).
• Paid time off, paid sick leave as provided under state and local paid sick leave laws.
• Short-term disability and optional long-term disability.
• Colleague and dependent life insurance and supplemental life and AD&D insurance.
• Tuition assistance.
• Employee assistance program that includes free counseling sessions.