Utilization Review RN - FT - Day - Utilization and Resource Mgmt Pennington NJ

Pay Range $39.40 - $51.47 for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time). Scheduled weekly hours: 40.

About the role

Performs a variety of utilization and resource management activities to promote quality, clinical and cost-effective outcomes. Assesses patients' treatment plans, communicates with third-party payers, and collaborates with healthcare team members. Performs functions that help optimize lengths of stay, utilize resources efficiently, and promote cost-effective practices without negatively impacting patient care. Adheres to established standards, practices, and procedures.

Requirements

• Associate's degree in nursing from an accredited school of nursing.
• Five years' clinical nursing experience.
• Three years' quality management, utilization review, or discharge planning experience.
• Registered Nurse (RN) license in New Jersey.
• CPHQ, CCM, or CPUR certification preferred.

Skills

• Basic computer skills including Microsoft Office, UR software, and EMR.
• Familiarity with MCG guidelines.
• Ability to solve practical problems and interpret instructions in written, oral, diagram, or schedule form.

Responsibilities

• Performs chart review of identified patients to assess quality, timeliness, and appropriateness of patient care.
• Conducts admission reviews for Medicare, Medicaid, private insurers, and self-pay patients using appropriate guidelines to determine inpatient level of care or observation services.
• Refers cases to the UR physician advisor for review and determination as needed.
• Gathers clinical information for continued stay utilization review activities with payers on a daily basis.
• Performs concurrent and retrospective clinical reviews with payers, adhering to applicable regulations, policies, and timelines.
• Follows CMS guidelines for utilization reviews, including appropriate referrals to the physician advisor and UR Committee.
• Identifies, develops, and implements strategies to reduce length of stay and resource consumption.
• Confers proactively with admitting physicians to provide coaching on accurate level of care determinations.
• Stays current on regulatory changes affecting delivery or reimbursement of acute care services.
• Applies knowledge of national and local coverage determinations to advise physicians appropriately.
• Understands and applies federal law regarding Hospital Initiated Notice of Non-Coverage (HINN) and Lifetime Reserve Days letters.
• Identifies and records progression of care or patient flow barriers using the Avoidable Days tool in Utilization software.
• Consults with medical staff, care team, and case managers to resolve progression of care barriers.
• Engages care team colleagues in collaborative problem-solving regarding appropriate resource utilization.
• Recognizes and responds appropriately to patient safety and risk factors.
• Represents Utilization Management at committees, professional organizations, and physician groups as needed.
• Promotes evidence-based protocols and order sets to influence high-quality, cost-effective care.
• Participates in performance improvement activities.
• Promotes medical documentation that accurately reflects findings, interventions, complications, and need for continued stay.
• Identifies and records episodes of preventable delays or avoidable days due to failure in progression of care.
• Maintains appropriate documentation in Utilization software for each patient, including resource utilization activities.
• Participates in daily huddles, patient care conferences, and handoff reports to track intensity of services and progression of care.
• Identifies potentially wasteful or misused resources and recommends alternatives by analyzing clinical protocols.
• Performs other duties as needed.

Physical Demands and Work Environment

• Frequent physical demands: Sitting, standing, walking.
• Occasional physical demands: Climbing (e.g., stairs or ladders), carrying objects, pushing/pulling, twisting, bending, reaching forward, reaching overhead, keyboard use/repetitive motion, talking, hearing.
• Continuous physical demands: Lifting up to 15 lbs from floor to waist or waist level and above.
• Sensory requirements: Accurate near vision, far vision, color discrimination, depth perception, and hearing.

Benefits

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