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Summary:

Responsible for application of appropriate medical necessity tools to maintain compliance and achieve cost effective and positive patient outcomes.

Acts as a resource to other team members including UR Tech and AA to support UR and revenue cycle process.

Position Responsibilities:

Utilization Management

• Utilizes Payer specific screening tools as a resource to assist in the determination process regarding level of service and medical necessity.

• Consults with Physician Advisor to discuss medical necessity, length of stay, and appropriateness of care issues.

• Identify and manage concurrent and retroactive denials through communication with attending physicians, case management, multidisciplinary team, external physician resource group and payers.

Documentation

• Appropriate and complete documentation of clinical review and denial management in the case management documentation system and in the billing system.

Denial Management

• Manages the concurrent denial process by referring to appropriate resource for concurrent and retrospective appeal activity process.

• Prepares and facilitates audits using appropriate screening tools and documentation.

Metrics

• Accountable to job specific goals, objectives and dashboards which contribute to the success of the organization.

• Participates in organizational improvement activities including patient satisfaction, Six Sigma committee, department and/or divisional teams and community activities.

Compliance

• Understands and applies applicable federal and state requirement.

• Identify and reports compliance issues as appropriate.

Position Qualifications Required / Experience Required:

Preferred: 3 years clinical nursing (RN) experience and 1 year UR/CM/QM experience or 3 years experience as Clinical Social Worker.

Basic understanding of Medicare, Medicaid and managed care.

Discharge planning or home health background.

Excellent verbal and written communication skills, problem solving, critical thinking and conflict resolution.

Required Education:

Graduate of an accredited School of Nursing.

Training/Certifications/Licensure:

Licensure from the State of New Jersey as a Registered Nurse.

Case Management Certification (requirement within one year of hire beginning April 1, 2015).

STAR Standards: Exhibits Virtua’s STAR Standards to create an outstanding patient experience. (Excellent Service, Clinical Quality and Safety, Best People, Caring Culture, Resource Stewardship).

Demonstrates Virtua values in all interactions with our customers, who are patients, families, physicians, co-workers and the community. (Integrity, Respect, Caring, Commitment, Teamwork, Excellence).

Hourly Rate: $37.21 - $57.68 The actual salary/rate will vary based on applicant’s experience as well as internal equity and alignment with market data.

Virtua offers a comprehensive package of benefits for full-time and part-time colleagues, including, but not limited to: medical/prescription, dental and vision insurance; health and dependent care flexible spending accounts; 403(b) (401(k) subject to collective bargaining agreement); paid time off, paid sick leave as provided under state and local paid sick leave laws, short-term disability and optional long-term disability, colleague and dependent life insurance and supplemental life and AD&D insurance; tuition assistance, and an employee assistance program that includes free counseling sessions. Eligibility for benefits is governed by the applicable plan documents and policies.

For more benefits information click here.