Job description

Reporting directly to the Medical Management Supervisor and indirectly to the Medical Management Administrator and Medical Services Director, the Utilization Review Nurse is a registered nurse who performs PIP and WC Utilization Review, Precertification and case management activities to ensure that claimants receive high quality, evidence-based, cost-efficient medical care in order to facilitate restoration of function, return to work and/or maximum medical improvement.

The successful candidate will perform all aspects of utilization management, including precertification/preauthorization review, concurrent review, retrospective review and case management intervention. The official NJM job title is Medical Management Coordinator.

Job Responsibilities:

• Complete comprehensive case assessments with a review of all available medical records. Assess the claimant’s medical and functional status in order to determine the appropriate level and type of care needed.
• Communicate regularly with hospitals directly or through liaison to obtain clinical information and updates needed to effectively and accurately perform concurrent review.
• Used evidence-based guidelines to manage inpatient hospitalizations/rehabilitation and ensure level of care and duration are medically necessary and compensable.
• Identify medical and community needs and facilitate/assist with post-discharge coordination of care.
• Conduct second level review on inpatient acute hospital and sub-acute rehabilitation bills, including the medical records, operative and diagnostic reports, itemized bills, and implant invoices to authorize appropriate reimbursement. Route for management approval, when required.
• Identify and report medical quality events, as required under the Quality Improvements Program.
• Review requests for precertification/pre-authorization of medical treatment/services for medical necessity and causality, including conservative care, surgery, medication, DME, and other treatment modalities. Ensure that the treatment requested is supported by medical evidence. Consult with and obtain direction from the Medical Director, NJM Physicians, and/or external physicians on medical necessity denials and complex cases.
• Accurately and concisely document all communications, activities and tasks in the claim systems, as required, in order to support claims management and data collection.
• Participate and support projects around medical management initiatives.
• Understand, apply, and comply with all statutory, regulatory, licensing requirements, and NJM policies/guidelines that affect utilization review, case management, and medical management work.
• Stays abreast of industry news and trends. Proactively seeks opportunities to increase knowledge on topics that impact property and casualty industry and medical community.
• Participate and support projects around medical management initiatives.
• Identify and/or support company and departmental business process improvements.

Required Skills & Experience:

• Actively licensed registered Nurse in New Jersey and Connecticut, Delaware, Maryland, New York or Pennsylvania.
• Bachelors of Science and Nursing (BSN) is preferred.
• Certified Case Manager (CCM) beneficial.
• 3 years of prior experience in clinical nursing (Med-Surg or Critical Care preferred), Utilization Management Review/Hospital concurrent reviews, and/or Case Management preferred.
• Knowledge of professional nursing principles, clinical practice guidelines and appropriate clinical interventions.
• Strong grasp of medical terminology, appropriate level of health care, treatment modalities, evidence-based guidelines (MCG and ODG preferred), and health care delivery systems.
• Strong relationship management skills, including the ability to develop a rapport with internal and external partners. Compassionate and empathetic. Demonstrated ability to influence others to gain buy-in and drive quality and evidence-based care.
• Collaborative and able to work well with teams.
• Demonstrated ability to problem-solve, and resolve complex, multifaceted, and emotionally-charged situations.
• Strong organizational and task prioritization skills.
• Attention to detail.
• Ability to navigate technology and multiple systems effortlessly and readily adapt to changes, when needed.
• Intermediate Microsoft Office Suite skills (Outlook, Word, Excel, PowerPoint)

Job Type: Full-time

Pay: $76,300.00 - $88,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Health insurance
• Life insurance
• Paid time off
• Tuition reimbursement

Physical setting:

• Office

Schedule:

• Monday to Friday

Supplemental pay types:

• Bonus pay

Ability to commute/relocate:

• Trenton, NJ 08628: Reliably commute or planning to relocate before starting work (Required)

Application Question(s):

• This is a hybrid role which will require a physical presence at our West Trenton headquarters two days per week. Are you able to commute to West Trenton?
• Please indicate your desired annual salary (Note: responses of N/A, negotiable or left blank will not be considered)

Work Location: One location

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