Utilization Review Manager RN

Salary Range : $90,000 - $110,000

When determining a base salary or hourly rate, several factors may be considered as applicable such as years of relevant experience, education, credentials.

About Christian Health :

We have had the privilege of caring for those in need for more than a century. Founded on the belief that everyone has the right to exceptional care, today we continue to provide quality care and services for our many residents, patients, and clients. Caring is not simply what we do, it is who we are.

Why Join Our Team :

Across our four campuses, eleven communities, five service offerings, and hospital, we are ultimately one unified team. Together, we nurture a compassionate, collaborative culture that enables continuous improvement and allows our team members to learn, grow, and shine in their careers. Surround yourself with people who care about making a difference – come join us!

We have an exciting opportunity for a full-time Utilization Review Manager RN to join our Utilization Review team. The Utilization Review Manager RN oversees and directs all operations of the Utilization Review department. Ensures the effective use and monitoring of healthcare resources to support positive clinical, financial, and operational outcomes. Reviews medical record documentation promptly to confirm compliance with regulatory and payer requirements. Verifies that documentation for all patients admitted to inpatient and partial hospitalization programs meets medical necessity criteria for the appropriate level of care. Monitors physician-ordered support services to ensure appropriate utilization. Collaborates with social services and participates in discharge planning as needed. Provides timely, accurate clinical reviews to maintain compliance with managed care organizations. Evaluates managed care denials and determines the risk and benefit of pursuing appeals. Demonstrates an understanding of, and embraces, the mission statement of Christian Health.

Competencies :

• Directs and coordinates the activities of the UR Nurse and UR Coordinator.
• Directs clinical activities of the UR department including oversight of effective work flow by effectively scheduling and directing work to assure timely and thorough completion.
• Ensures appropriate staffing and scheduling of UR to meet demands.
• Ensures accurate and updated statistical database regarding denied cases.
• Provides financial information to patients including but not limited to managed care, Medicare / Medicaid, charity care, etc., and provides guidance and / or refers to finance department, as necessary.
• Ensures the accurate exchange of information and coordination of operations from all programs to maintain.
• Verifies all insurance pre-certifications received from sending hospitals.
• Develops, monitors, reviews, and reports on Department specific QAPI initiatives.
• Participates in policy and procedure review and updates for the UR Department of other CH P&P, as needed.
• Provides the VP of Revenue Cycle with regular verbal / written feedback and reports, as needed, to ensure optimal operational functioning of the department.
• Plans, implements, and evaluates projects related to improving operational efficiencies / productivity.
• Attends all meetings, as scheduled, to review patient activities.
• Oversees the orientation and onboarding of new department staff.
• Actively serves on Christian Health-wide and / or department specific committees, as directed.
• Maintains accrediting and / or regulatory agency survey readiness at all times.
• Demonstrates competency to interact with patients ages 18 and older including geriatric patients with Dementia.
• Performs admission continued extended stay reviews as required.
• Performs concurrent reviews which required outside agencies for reimbursement authorizations essential several times daily obtains insurance / MCO pre cert and continued state authorizations as required.
• Performs insurance verification and secure his billing and benefit information.
• Performs other related duties as deemed necessary and appropriate, as directed.

Qualifications :

Schedule : 8am-4pm, Monday - Friday.

Education : A graduate of an accredited school of nursing or a nursing degree from an accredited college or university. Must be a Registered Nurse in the state of New Jersey.

Christian Health offers a wide variety of benefits to full-time employees that includes :

If you are interested in this great opportunity, please apply today on our website listed below.

careers