Utilization Management Director jobs in Atlantic City, NJ

POSITION SUMMARY

The RN Utilization Management Days is responsible for the overall Utilization Management process for assigned patient population. This includes reviewing clinical information to determine the appropriate level of care assignment, along with the completion and submission of reviews to insurance payers with appropriate follow-up. The RN utilizes designated criteria/guidelines to determine and document the medical necessity and appropriate level of care. This position analyzes clinical information received to facilitate authorization from insurance providers, maximize reimbursement by preventing denials, and ensures clinical data is sufficient to obtain an authorization. This position ensures that the obligation for clinical review is met according to the payer contracts and validates the accuracy of insurance information in the system. The RN is knowledgeable of the payer contracting arrangements, admission notification and clinical review requirements, as well as the regulatory and compliance requirements for government payers regarding clinical reviews and medical necessity. This role ensures that appropriate and accurate information is placed into the patient accounting system for processing of payment. This role also provides notification of denial issues and potential avoidance of a denial, along with changes in insurance information to all appropriate areas (e.g. clinical team, Patient Accounting). The RN supports system-wide improvement initiatives within the hospitals and the medical staff structure to ensure effective and timely performance improvement. This role Participates in UR Committee work as requested.

QUALIFICATIONS

EDUCATION: Graduate of an accredited school of nursing required. Bachelor's in Nursing preferred. Case Management certification preferred.

LICENSE/CERTIFICATION: Current licensure as a Registered Nurse in the State of New Jersey

EXPERIENCE: Prior case management/insurance case management experience preferred. Proficiency in Clinical Applications preferred at time of hire; incumbents within position will be trained appropriately and then skill will be required for this position within 30-60 days from date of hire.

PERFORMANCE EXPECTATIONS

Demonstrates the technical competencies as established on the Assessment and Evaluation Tool.

WORK ENVIRONMENT

This position requires desk/computer work a majority of the time. There is some standing, walking and occasional lifting up to 20 pounds. The essential functions for this position are listed on the Assessment and Evaluation Tool.

REPORTING RELATIONSHIP

This position reports to department leadership.

The above statement reflect the general details considered necessary to describe the principle functions of the job as identified and shall not be considered as a detailed description of all work requirements that may be inherent in the position.