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Hackensack Meridian Health · 5 months ago

Care Management, Care Coordinator, Utilization Management

Hackensack, NJ

Full-time

Onsite

Mid Level

$112K/yr - $112K/yr

Hackensack Meridian Health is dedicated to helping patients live healthier lives and fostering a collaborative work environment. The Care Management, Care Coordinator, Utilization Management is responsible for coordinating patient treatment, managing caseloads, and ensuring compliance with healthcare standards and regulations in New Jersey.

Assisted LivingHealth CareHealth DiagnosticsHospitalMedical

Responsibilities

Follows departmental workflows for utilization review activities including admission reviews, admission denials, continued stay reviews, continued stay denials, termination of benefits, communication of information to insurance company, billing certifications, concurrent managed care denial appeals and retrospective medical record utilization reviews

Obtains and evaluates medical records for inpatient admissions to determine if required documentation is present

Obtains appropriate records as required by payer agencies and initiates physician advisor's review as necessary for unwarranted admissions

Performs chart reviews for appropriateness of admission and continued hospital stay applying appropriate clinical criteria. Performs admission review within 24 hours or the first business day

Refers cases not meeting criteria to the physician advisor or designated vendor for determination and action

Participates actively on appropriate committees, workgroups, and or meetings

Identifies and refers quality issues for review to the Quality Management Program

Participates in multidisciplinary rounds, specific to assigned units. Brings forth issues which impact discharge and length of stay in a timely manner

Performs appropriate reassessments and evaluates progress against care goals and the plan of care and revises plans, as needed

Collaborates with all members of the multidisciplinary team to support length of stay reduction and observation management goals

Provides appropriate CMS documents to the patient and family/support person as per regulatory guidelines (ie., Important Message 4 to 48 hours prior to discharge, appeal and HINN notices)

Maintains annual competencies and completes training and continuing education in applicable platforms. (Epic, Xsolis Cortex, Enterprise Analytics, Google Suites)

Adheres to the Medical Center's Organization Competencies and the Standard of Behavior

Other duties as assigned

Qualification

NJ State RN LicenseUtilization ManagementCertified Case ManagerEpicComputer skillsCommunity resources knowledgeEffective decision-makingProblem-solvingLeadership skillsVerbal communicationWritten communicationPresentation skills

Required

BSN or BSN in progress and/or willing to acquire within 3 years of hire or transfer into the position

Effective decision-making skills, demonstration of creativity in problem-solving, and influential leadership skills

Excellent verbal, written and presentation skills

Moderate to expert computer skills

Familiar with hospital resources, community resources, and utilization management

NJ State Professional Registered Nurse License

AHA Basic Health Care Life Support HCP Certification

Preferred

Certified Case Manager (CCM), Certified Clinical Medical Assistant (CCMA), or American Case Management Association (ACMA) certification strongly preferred