Utilization Mgmt Coordinator


CORPORATE Edison Requisition # 2019-70745 ShiftDay StatusFull Time with Benefits Weekend WorkNo Weekends Required HolidaysNo Holidays Required On CallNo On-Call Required Standard hours per week40 Address343 Thornall Street

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Overview

How have you impacted someone's life today? At Hackensack Meridian Health our teams are focused on changing the lives of our patients by providing the highest level of care each and every day. From our hospitals, rehab centers and occupational health teams to our long-term care centers and at-home care capabilities, our complete spectrum of services will allow you to apply your skills in multiple settings while building your career, all within New Jersey's premier healthcare system.

The Utilization Management Coordinator oversees and facilitates medical necessity and technical appeals for inpatient and/or outpatient claims for managed care as the result of denials and/or RAC denials. Serve as a functional expert and liaison on appeals as may be directed for care coordination staff and other hospital departments.

Responsibilities

 

  • Admission Denials
  • Continue Stay Denials
  • Communication of Information to
  • Insurance Companies
  • DOBI Denials / Appeals
  • Inpatient Managed Care Denials and Appeals
  • Outpatient Managed Care Denials and Appeals
  • RAC Denials and Appeals
  • Technical Denials
  • Reviews and analyzes standards and requirements established by regulatory agencies and third party payers, which govern inpatient, outpatient and/or RAC admissions, treatments, continued stays and discharges.
  • Obtains and evaluates medical records for inpatient and/or RAC admissions to determine if required documentation is present
  • Performs chart reviews for appropriateness of admission and continued hospital stay applying appropriate clinical criteria.

Qualifications

  • Valid NJ nursing license required
  • Case Management / Utilization Management experience preferred
  • 4-5 years of RN experience required
  • CCM OR ACM preferred
  • Good communication and interpersonal skills
  • Knowledge of third party payers and/or managed care principles.
  • Knowledge of InterQual/MCG criteria and other guidelines for medical necessity, setting and level of care and concurrent patient management.
  • Computer skills to include Microsoft Work, Excel and basic entry.
  • Experience with the AllScripts Utilization Management software program or comparable electronic review program (EPIC, Indicia, Maxsys).
  • Knowledge of third party payers and/or managed care principles.
  • Knowledge of InterQual/MCG criteria and other guidelines for medical necessity, setting and level of care, and concurrent patient management.
  • Knowledge of health care delivery system, utilization review and case review procedures.

Our Network

As a courtesy to assist you in your job search, we would like to send your resume to other areas of our Hackensack Meridian Health network who may have current openings that fit your skills and experience.