Care Management, Care Coordinator, Utilization Management

Hackensack Meridian Health • Neptune Township, NJ

3d

About The Position

The Care Coordinator, Utilization Management is a member of the healthcare team who coordinates, communicates, and facilitates the clinical progression of patients’ treatment. The position is accountable for a designated patient caseload and plans effectively to manage length of stay, promote efficient use of resources, and ensure care meets evidence-based practice standards and regulatory and payer requirements, including New Jersey nursing regulations.

The role conducts utilization review activities and evaluates medical records and clinical criteria for inpatient admissions and continued hospital stays. It works with physician advisors, payer agencies, patients and families, and multidisciplinary teams to address reviews, denials, appeals, discharge needs, and length-of-stay goals. The position also participates in committees and rounds, supports quality review, maintains required competencies and training, and follows HMH organizational competencies and standards of behavior.

Requirements

• BSN, or BSN in progress, and/or willingness to acquire a BSN within three years of hire or transfer into the position.
• Effective decision-making skills, creativity in problem-solving, and influential leadership skills.
• Excellent verbal, written, and presentation skills.
• Moderate to expert computer skills.
• Familiarity with hospital resources, community resources, and utilization management.
• NJ State Professional Registered Nurse License.
• AHA Basic Health Care Life Support HCP Certification.

Nice To Haves

• Certified Case Manager (CCM), Certified Clinical Medical Assistant (CCMA), or American Case Management Association (ACMA) certification is strongly preferred.

Responsibilities

• Follow departmental workflows for utilization review, including admission and continued-stay reviews and denials, termination of benefits, payer communications, billing certifications, concurrent managed-care denial appeals, and retrospective medical-record utilization reviews.
• Obtain and evaluate inpatient admission medical records to determine whether required documentation is present.
• Obtain records requested by payer agencies and initiate physician advisor review as necessary for unwarranted admissions.
• Review charts for appropriateness of admission and continued hospital stay using appropriate clinical criteria; complete admission reviews within 24 hours or the first business day.
• Refer cases that do not meet criteria to the physician advisor or designated vendor for determination and action.
• Participate in appropriate committees, workgroups, and meetings.
• Identify and refer quality issues for review to the Quality Management Program.
• Participate in multidisciplinary rounds for assigned units and raise issues affecting discharge and length of stay in a timely manner.
• Perform reassessments, evaluate progress toward care goals and the plan of care, and revise plans as needed.
• Collaborate with multidisciplinary team members to support length-of-stay reduction and observation management goals.
• Provide patients and their families or support persons with appropriate CMS documents in accordance with regulatory guidelines, including Important Message documents 4 to 48 hours before discharge, appeal notices, and HINN notices.
• Maintain annual competencies and complete training and continuing education in applicable platforms, including Epic, Xsolis Cortex, Enterprise Analytics, and Google Suites.
• Perform other duties and projects as assigned.
• Adhere to HMH organizational competencies and standards of behavior.

Benefits

• Comprehensive benefits package including health, dental, and vision coverage, paid leave, tuition reimbursement, and retirement benefits.
• Some positions may be eligible for performance-based incentives, bonuses, or commissions.
• Certain positions may be eligible for shift differentials for evening, night, or weekend shifts.

What This Job Offers

• Job Type: Full-time