RN CASE MANAGER

3 weeks ago

Trenton NJ USA, United States NJM Insurance Group Full time
NJM Insurance Group currently has an RN Case Manager opportunity to assure that claimants receive high quality, cost-effective medical care with positive outcomes. The successful candidate is results-oriented and will perform all aspects of utilization management: case management intervention, precertification, concurrent review, and retrospective review.

This position will require some travel. The official NJM job title is Medical Management Coordinator.

Job Responsibilities:
  • Provide Case Management services to a caseload of approximately 40-50 claimants, which includes: comprehensive assessment, planning, implementation and overall evaluation of individual claimant needs.
  • Collaborate with treatment providers to promote rehabilitation.
  • Review clinical information and perform utilization management, concurrent and retrospective, utilizing established evidence-based clinical guidelines to evaluate treatment plans and/or manage inpatient length of stay.
  • Review precertification/preauthorization requests for medical necessity and ensure that treatment is supported by treatment guidelines, medical policies, and/or medical evidence. Refer cases that don't meet established guidelines for medical necessity to Medical Director for additional review.
  • Maintain accurate records of all communication and interventions, including documentation in the claim system.
  • Participate and support projects around medical management initiatives.
  • Monitor all utilization reports to ensure compliance and identify trends.
  • Assist with preparation of reports, as needed.
  • Support company and departmental Quality Assurance/Quality Improvement initiatives.
  • Keep current with regulation changes.

Required Qualifications and Experience:
  • Registered Nurse (RN) in New Jersey
  • 3 + years of experience preferred in: Med-Surg and critical care and clinical nursing, Utilization Management Review/Hospital concurrent reviews, and/or Hospital Bill Auditing for inappropriate charges, denials and uncertified days.
  • Knowledge of professional nursing principles, clinical practice guidelines, and clinical interventions.
  • Experience with medical record reviews, medical terminology, appropriate level of health care, treatment modalities and health care delivery systems.
  • Excellent relationship management skills, including the ability to influence and/or mentor others with varying levels of experience.
  • Demonstrated ability to problem-solve and resolve complex, multifaceted, and emotionally-charged situations. Competence in negotiation, quality assurance, case management outcomes, and data analysis.
  • Ability to travel within NJ.
  • Strong organizational, task prioritization and delegation skills.
  • Experience with Microsoft Office products and database programs, data analysis and data management proficiency.

Preferred:
  • Experience in Workers Compensation and/or PIP.
  • BSN from an accredited school of nursing.
  • Experience with Utilization Review/Hospital Concurrent Review (monitoring hospital/rehab stays for medical necessity and intensity of service).
  • Knowledge of MCG/Millman, Official Disability Guidelines (ODG) and/or other evidence-based guidelines databases.

Legal Disclaimer: NJM is proud to be an equal opportunity employer. We are committed to attracting, retaining and promoting a diverse and inclusive workforce that is fully representative of the diversity that exists in the communities in which we do business.

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