Utilization Review Nurse - (RN) - Part Time - Benefit Eligible - Days

CentraState Healthcare System-posted 5 days ago
Part-time • Mid Level
Freehold, NJ
5,001-10,000 employees
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CentraState Healthcare System, headquartered in Freehold, New Jersey, is a leading nonprofit healthcare provider dedicated to serving the community. Its comprehensive network includes CentraState Medical Center, a community-focused hospital, along with an ambulatory campus, two senior living facilities, three free-standing community health pavilions, and a charitable foundation. As the third-largest employer in Monmouth County, CentraState has earned repeated recognition as a Great Place to Work-Certified™ company, reinforcing its reputation as an exceptional workplace. CentraState Medical Center has an employment opportunity available for a Utilization Review Nurse . The Utilization Review RN (UR RN) applies professional nursing judgment and critical thinking skills to assess patients for appropriate levels of care and to mitigate potential denials. This role requires a strong knowledge of evidence-based clinical criteria and federal and state utilization management requirements. The UR RN identifies key clinical information to support hospital admissions and continued stays, collaborates with the care management team to optimize resource utilization, and secures payer approvals. The UR RN also reviews escalated cases that do not meet medical necessity prior to initiating secondary review.

  • Provides timely and thorough clinical information to insurance companies and other intermediaries to secure payer authorizations and avoid denials or reduction in level of care.
  • Performs daily surveillance of observation cases and works with APNs and PA discussing any barriers to progression of care or discharge.
  • Intervenes proactively to avoid denials or delays in authorization.
  • Actively communicates information to other CM team members and interdisciplinary teams regarding progress or payer issues related to continued hospitalization and post-acute service associated with the patients discharge plan.
  • Refers cases and issues to Physician Advisors or Designees in compliance with department procedures with timely follow up as indicated.
  • Assists in identification and collection of avoidable days and management of the expected discharge date.
  • Coordinates with the CM RN and/or CMA to identify and complete the process for CMS required patient notices.
  • Completes and documents utilization reviews, physician advisor referrals and other communications related to assigned cases in accordance with department policy and procedure.
  • Complies with the Condition of Code 44 process, CMS required patient notices and other regulatory requirements within the utilization management process.
  • Maintains proficiency in the application of organization selected clinical review criteria sets evidenced through IRR testing
  • Assists in facilitating and coordinating clinical progression of assigned patients
  • Other duties as assigned by management
  • BSN or Bachelor's Degree in related field or current enrollment in BSN or related Bachelor's Degree program required.
  • Prior clinical experience in care and management of hospitalized patients.
  • RN license required/NJ.
  • Excellent communication, negotiation, and conflict resolution skills
  • Data and computer skills
  • Knowledge of relevant and state utilization review and appeals requirements
  • Experience in acute care case management, preferred.
  • Utilization review or case management training from a professional Case Management organization, preferred.
  • Case Management certification preferred.
  • Rapid cycle change or clinical performance improvement expertise
  • Medical, Dental, Vision, Prescription Coverage (30 hours per week or above for full-time and part-time team members)
  • Life & AD&D Insurance
  • Long-Term Disability (with options to supplement)
  • 403(b) Retirement Plan with employer match
  • 401(a) Retirement Plan with employer contribution
  • PTO
  • Tuition Reimbursement
  • Well-Being Rewards
  • Employee Assistance Program (EAP)
  • Fertility Coverage, Healthy Pregnancy Program
  • Flexible Spending & Commuter Accounts
  • Pet, Home & Auto, Identity Theft and Legal Insurance
  • Growth Opportunity and Workforce Development Initiatives
  • Continuing Education / Onsite Training
  • A warm, welcoming company culture based upon mutual respect and a collaborative goal of providing excellent patient care
  • Concierge Services with Work & Family Benefits
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