Utilization Review Manager - Home Care jobs in Trenton, NJ

Job Details

Description

Position Summary: The Utilization Review Case Manager validates the patient’s placement to be at the most appropriate level of care based on nationally accepted admission criteria. The UR Case Manager uses medical necessity screening tools, such as InterQual or MCG criteria, to complete initial and continued stay reviews in determining appropriate level of patient care, appropriateness of tests/procedures and an estimation of the patient’s expected length of stay. The UR Case Manager secures authorization for the patient’s clinical services through timely collaboration and communication with payers as required. The UR Case Manager follows the UR process as defined in the Utilization Review Plan in accordance with the CMS Conditions of Participation for Utilization Review

Experience

Required: 3 to 5 years acute care nursing experience

Preferred: Experience in case management

Education

Required: Graduate of accredited diploma, associate degree or baccalaureate degree nursing program

Preferred: BSN preferred

License and Credentials

Required: NJ RN licensure

Preferred: Certification in case management

Skills

Required: Current sound clinical knowledge; knowledge of medical literature, research methodology, financial/ reimbursement issues. Strong collaboration, communication and interpersonal skills. Excellent organizational and time management skills. Knowledge of computers, Electronic Health Records, data base systems and utilization review/case management documentation systems. Desire to work collaboratively and proactively with healthcare teams and other hospital-based interdisciplinary teams. Current knowledge of discharge planning, resource management, and care coordination in an acute care setting. Knowledge of CMS, commercial payer requirements and hospital financial/reimbursement processes. Excellent written/verbal communication skills, critical thinking skills, creative problem solving skills, good organizational and planning skills. Must be self-directed, have the ability to tolerate frequent interruption and work in a fast-paced work environment. Knowledge of funding, resources, services, clinical standards, care coordination processes and outcomes is preferred. Weekend, Holiday and on call may be required.

Bi-Weekly Hours: Per-Diem, Varied Shifts

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