In accordance with the objective and goals of the Utilization Management Plan, the UM Coordinator coordinates and monitors daily activities of the utilization management functions of the Care Management Department, ensuring appropriate allocation of hospital resources while maintaining quality of patient care. This position also holds the responsibility for ensuring regulatory compliance requirements and coordinating the medical management aspects of clinical review requests from external entities.
Review Activities: Admission review, admission denial, continued stay review, continued stay denial, termination of benefits, communication of information to insurance company, billing certification, concurrent managed care, Denial Appeals, retrospective medical record utilization review. Obtains and evaluates medical records for in patient admissions to determine if required documentation is present. Obtains appropriate records as required by payer agencies and initiates physician advisor's as necessary for unwarranted admissions. Conducts on going review and discusses care changes with attending physicians and others. Performs chart reviews for appropriateness of admission and continued hospital stay applying appropriate clinical criteria. Performs admission review within 24 hours or the first business day. Refers cases not meeting criteria to the physician adviser for determination and action.
RN BSN preferred
Certified Case Manager preferred
Licensed as a registered nurse in the state of New Jersey
Minimum of five years experience in the acute care setting
Previous case management/utilization review experience preferred
Knowledge of federal and state regulations, third party payers/managed care principles
Knowledge of Milliman criteria and other guidelines for medical necessity, appropriate level of care and concurrent patient management
Knowledge of health care delivery system, utilization review and case review procedures
Computer skills to include Microsoft Word, Excel and basic data entry
Strong organizational and problem solving skills
Excellent oral, written and interpersonal skills