Clinical Denials Utilization Review RN - FT - Day - Utilization Resource Management Pennington NJ

Position Overview

Performs Utilization Review function for Capital Health related to third party reimbursement, denials, appeals and clinical audits for inpatient cases. Ensures responsibility for Performance Improvement, and Quality Improvement activities in department. Prepares and submits appeals timely and ensures completion of UR inpatient appeal process.

Minimum Requirements

• Education: Graduation from an accredited School of Registered Nursing.
• Experience: Five years' experience in nursing. Three years' experience in case management field including utilization review, discharge planning, outcomes management, assessment, care planning, and/or care coordination. Inpatient denial appeal experience preferred.

Other Credentials

• Registered Nurse - NJ
• Knowledge and Skills: Knowledge of CMS guidelines, payor specific guidelines, contractual rules, and applicable clinical guidelines. Ability to interpret a variety of instructions furnished in written, oral, diagram or schedule form.
• Special Training: Proficient in word, excel, outlook, and other Utilization review software and patient information EMR software.

Mental, Behavioral And Emotional Abilities

• Usual Work Day: 8 Hours
• Reporting Relationships: Does this position formally supervise employees? No

Physical Demands and Work Environment

• Frequent physical demands include: Sitting, Standing, Keyboard use/repetitive motion
• Occasional physical demands include: Walking, Climbing (e.g., stairs or ladders), Carry objects, Push/Pull, Twisting, Bending, Reaching forward, Reaching overhead, Squat/kneel/crawl, Wrist position deviation, Pinching/fine motor activities
• Continuous Physical Demands Include: Lifting Floor to Waist 15 lbs. Lifting Waist Level and Above 10 lbs.
• Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Color Discrimination, Minimal Depth Perception, Minimal Hearing

Anticipated Occupational Exposure Risks

• Anticipated Occupational Exposure Risks Include the following: Bloodborne Pathogens, Chemical, Airborne Communicable Disease

Benefits

• Medical Plan
• Prescription drug coverage & In-House Employee Pharmacy
• Dental Plan
• Vision Plan
• Flexible Spending Account (FSA)
• Healthcare FSA
• Dependent Care FSA
• Retail Savings and Investment Plan
• Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance
• Supplemental Group Term Life & Accidental Death & Dismemberment Insurance
• Disability Benefits – Long Term Disability (LTD)
• Disability Benefits – Short Term Disability (STD)
• Employee Assistance Program
• Commuter Transit
• Commuter Parking
• Supplemental Life Insurance
• Voluntary Life Spouse Voluntary Life
• Employee Voluntary Life
• Child Voluntary Life
• Voluntary Legal Services
• Voluntary Accident, Critical Illness and Hospital Indemnity Insurance
• Voluntary Identity Theft Insurance
• Voluntary Pet Insurance
• Paid Time-Off Program