Registered Nurse - Utilization Management - Full Time

AtlantiCare•Egg Harbor Township, NJ

3d•Onsite

About The Position

The RN Utilization Management is responsible for the overall Utilization Management process for assigned patient population. This includes reviewing clinical information to determine the appropriate level of care assignment, along with the completion and submission of reviews to insurance payers with appropriate follow-up. The RN utilizes Evidenced Based "MCG" criteria/guidelines and other approved Atlanticare applications to assess and document the medical necessity and appropriate patient status/level of care determination. This position analyzes clinical information received to facilitate authorization from insurance providers, maximize reimbursement by preventing denials, and ensures clinical data is sufficient to obtain an authorization. The RN works closely with Physician Advisors (PAs) to confirm that status and level-of-care mismatches, along with provider documentation concerns, are thoroughly reviewed and addressed, including follow-up on final decisions and peer-to-peer discussion outcomes as required. This position ensures that the obligation for clinical review is met according to the payer contracts and validates the accuracy of insurance information in the system. The RN is knowledgeable of the payer contracting arrangements, admission notification and clinical review requirements, as well as the regulatory and compliance requirements for government payers regarding clinical reviews and medical necessity. This role ensures that appropriate and accurate information is placed into the patient accounting system to result in clean, compliant, and timely claim processing. This role also provides notification of denial issues and potential avoidance of a denial, along with changes in insurance information to all appropriate areas (e.g. clinical team, Patient Accounting). The RN supports system-wide improvement initiatives within the hospitals and the medical staff structure to ensure effective and timely performance improvement. This role Participates in UR Committee work as requested.

Requirements

Graduate of an accredited school of nursing required.
Bachelor's in nursing Required.
Current licensure as a Registered Nurse in the State of New Jersey or current multi state license required.
Current MCG (Milliman Clinical Guideline) certification required within 2 years of hire or transfer (Current incumbents must obtain MCG by 1/1/2027).
American Heart Association BLS certification required within 6 months of hire or transfer (Current incumbents must obtain BLS by 6/30/2026).

Nice To Haves

Utilization/Coding certification preferred or in process.
Prior Utilization/insurance case management experience Preferred.
Experience on MCG/InterQual, HEDIS, CDI or Quality review preferred.
Recent acute care Medical-Surgical nursing experience preferred.
Proficient in using common computer software applications preferred (Word, Excel formatting).
Proficiency in Clinical Applications preferred at time of hire; incumbents within position will be trained appropriately and then skill will be required for this position within 30-60 days from date of hire.

Responsibilities

Review clinical information to determine appropriate level of care assignment.
Complete and submit reviews to insurance payers with appropriate follow-up.
Utilize Evidenced Based "MCG" criteria/guidelines and other approved Atlanticare applications to assess and document medical necessity and appropriate patient status/level of care determination.
Analyze clinical information to facilitate authorization from insurance providers.
Maximize reimbursement by preventing denials and ensuring clinical data is sufficient to obtain authorization.
Work closely with Physician Advisors (PAs) to confirm and address status and level-of-care mismatches and provider documentation concerns.
Follow up on final decisions and peer-to-peer discussion outcomes.
Ensure clinical review obligations are met according to payer contracts.
Validate the accuracy of insurance information in the system.
Ensure appropriate and accurate information is placed into the patient accounting system for clean, compliant, and timely claim processing.
Provide notification of denial issues and potential avoidance of denial, along with changes in insurance information, to appropriate areas.
Support system-wide improvement initiatives within hospitals and the medical staff structure.
Participate in UR Committee work as requested.