Inpatient Utilization Management for NJ Facilities -
The candidate will be responsible to collaborate with healthcare providers and Medicaid members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for more complex medical issues. Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards accurately interpreting benefits and Medicaid products, and steering members to appropriate providers, programs or community resources. Works with medical directors in interpreting appropriateness of care and accurate claims payment. This role involves telephonic duties, with a hybrid schedule that requires in-office work in Iselin, NJ once per quarter or as directed by the UM Manager.
Primary duties may include, but are not limited to:
Conducts continued stay review and discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.
Collaborates with providers to assess member's needs for early identification of and proactive planning for discharge planning.
Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications.
Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and NJ regulatory requirements and standards.
Serves as resource to lower-leveled nurses and may participate in or lead intradepartmental teams, projects and initiatives.
Requirements:
Current active valid unrestricted New Jersey RN license to practice as a health professional in applicable state(s) or territory of the United States.
A minimum of 5 years acute care clinical experience or case management, utilization management or managed care experience; or any combination of education and experience, which would provide an equivalent background.
Knowledge of medical management process and ability to interpret and apply member Medicaid benefits, and managed care products strongly preferred.
Prior NJ Medicaid experience strongly preferred.
Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills preferred.
Participation in the American Association of Managed Care Nurses preferred.
