Utilization Review Case Manager, Care Coordination, Per Diem, Day

About the role

The Utilization Case Manager performs concurrent utilization review to ensure appropriate level-of-care determinations, medical necessity, regulatory compliance, and effective resource utilization. Collaborates with physicians, payers, Physician Advisors, and care coordination staff to support admission status decisions, prevent reimbursement denials, optimize length of stay, and ensure compliance with CMS and payer requirements. Serves as a resource on utilization management, medical necessity criteria, and reimbursement regulations while promoting quality patient outcomes and organizational performance.

Responsibilities

• Perform concurrent utilization review for appropriate level-of-care determinations and medical necessity
• Ensure regulatory compliance and effective resource utilization
• Collaborate with physicians, payers, Physician Advisors, and care coordination staff
• Support admission status decisions and prevent reimbursement denials
• Optimize length of stay and ensure compliance with CMS and payer requirements
• Serve as a resource on utilization management, medical necessity criteria, and reimbursement regulations
• Promote quality patient outcomes and organizational performance

Requirements

• Bachelor's degree (BSN) in nursing required
• Current Registered Nurse (RN) License in the State of New Jersey required
• Experience in case management and/or utilization review strongly preferred

Skills

• 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 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 in electronic medical records and case management software
• Ability to manage multiple priorities in a fast-paced environment while maintaining 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

Schedule

• Shift: Day
• Location: The Valley Hospital-Paramus

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 (e.g., Short-term and Long-term Disability, Whole Life Insurance, Legal Support, etc.)
• 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

Pay

Pay Range: $50.18 - $62.73 per hour

Starting salary and benefits in accordance with role, experience, education, and licensure. Actual individual salaries vary depending on these factors. The salary listed does not include other forms of compensation or benefits.