Utilization Review Case Manager, Care Coordination, Per Diem, Day
Valley Health System•Paramus, NJ
•$50 - $63•Onsite
About The Position
The Utilization Case Manager performs concurrent utilization review to ensure appropriate level-of-care determinations, medical necessity, regulatory compliance, and effective resource utilization. The role collaborates with physicians, payers, Physician Advisors, and care coordination staff to support admission status decisions, prevent reimbursement denials, optimize length of stay, and comply with CMS and payer requirements. The position serves as a resource on utilization management, medical necessity criteria, and reimbursement regulations while promoting quality patient outcomes and organizational performance.
Requirements
- Bachelor's degree (BSN) in nursing.
- Current Registered Nurse (RN) license in the State of New Jersey.
- Knowledge of acute care nursing practice, utilization review principles, medical necessity criteria, MCG guidelines, and applicable CMS, Medicare, Medicaid, and commercial payer requirements.
- Understanding of healthcare documentation standards, reimbursement processes, and utilization management practices.
- Strong communication and collaboration skills when working with physicians, payers, patients, families, and interdisciplinary teams.
- Critical thinking, clinical reasoning, and analytical skills to evaluate medical necessity, interpret clinical documentation, and resolve utilization management concerns.
- Proficiency with electronic medical records and case management software.
- Ability to manage multiple priorities in a fast-paced environment with accuracy and attention to detail.
- Ability to interpret complex clinical and regulatory information, work effectively with diverse stakeholders, and remain professional and composed when addressing challenging situations, changing priorities, and reimbursement-related issues.
Nice To Haves
- Experience in case management and/or utilization review.
Responsibilities
- Perform concurrent utilization review to evaluate level of care, medical necessity, regulatory compliance, and resource utilization.
- Collaborate with physicians, payers, Physician Advisors, and care coordination staff on admission status decisions.
- Help prevent reimbursement denials and optimize length of stay.
- Ensure compliance with CMS and payer requirements.
- Serve as a resource on utilization management, medical necessity criteria, and reimbursement regulations.
- Evaluate clinical documentation and address utilization management concerns.
Benefits
- Medical/Prescription, Dental & Vision Discount Program (Full Time/Part Time Employees)
- Group Term Life Insurance and AD&D (Full Time Employees)
- Flexible Spending Accounts and Commuter Benefit Plans
- Supplemental Voluntary Benefits, such as Short-term and Long-term Disability, Whole Life Insurance, and Legal Support
- 6 Paid Holidays
- Paid Time Off (varies)
- Wellness Time Off
- Extended Illness
- Retirement Plan
- Tuition Assistance
- Employee Assistance Program (EAP)
- Valley Health LifeStyles Fitness Center Membership Discount
- Day Care Discounts for Various Daycare Facilities
