RN Case Manager
2 days ago
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/Field Nurse Case Manager.
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 dont 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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