Cape Regional Health System is an integrated healthcare delivery system serving residents and visitors throughout Cape May County. We seek to hire a Utilization Review RN Care Manager who will embrace our mission to provide the highest quality healthcare to our community.

The Utilization Review RN is a member of the healthcare team and is responsible for coordinating, communicating, and facilitating the clinical progression of the patient's treatment. Accountable for a designated patient caseload; the Utilization Review RN plans effectively in order to manage length of stay, promote efficient utilization of resources and ensure that care meets evidence-based practice standards and regulatory/payor requirements and follows the state of New Jersey regulations for Nursing.

Qualifications:

Education, Knowledge, Skills and Abilities Required:

1. Bachelor's degree, Nursing

2. Effective decision-making skills, demonstration of creativity in problem-solving, and influential leadership skills.

3. Excellent verbal, written and presentation skills

4. Moderate to expert computer skills

5. Familiar with hospital resources, community resources, and utilization management Education, Knowledge, Skills and Abilities Preferred.

Licenses and Certifications Required:

1. NJ State Professional Registered Nurse License.

2. Basic Health Care Life Support Certification.

3. Care Management certification by a nationally recognized organization within 2 years.

Responsibilities:

1. Follows departmental workflows for utilization review activities including admission reviews, admission denials, continued stay reviews, continued stay denials, termination of benefits, communication of information to insurance company, billing certifications, concurrent managed care denial appeals and retrospective medical record utilization reviews.

2. Obtains and evaluates medical records for inpatient admissions to determine if required documentation is present.

3. Obtains appropriate records as required by payer agencies and initiates physician advisor's review as necessary for unwarranted admissions.

4. 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.

5. Refers cases not meeting criteria to the physician advisor for determination and action.

6. Participates actively on appropriate committees, workgroups, and or meetings.

7. Identifies and refers quality issues for review to the Quality Management Program.

8. Participates in multidisciplinary rounds, specific to assigned units. Brings forth issues which impact discharge and length of stay in a timely manner.

9. Performs appropriate reassessments and evaluates progress against care goals and the plan of care and revises plans, as needed

10. Collaborates with all members of the multidisciplinary team to support length of stay reduction and observation management goals.

11. Provides appropriate CMS documents to the patient and family/support person as per regulatory guidelines (ie., Important Message 4 to 48 hours prior to discharge, notice of Observation (MOON), appeal and HINN notices)

12. Maintains annual competencies and completes training and continuing education in applicable platforms.

13. Adheres to the Medical Center’s Organization Competencies and the Standard of Behavior.

14. Other duties as assigned