Healthcare Utilization Management Coordinator

2 weeks ago

Hackensack, New Jersey, United States Hackensack Meridian Health Full time

Overview

At Hackensack Meridian Health, our team members are essential to our mission of enhancing patient care and fostering a supportive environment. We are dedicated to helping our patients lead healthier lives while also empowering our staff to thrive. Our culture emphasizes collaboration and connection, ensuring that we not only provide competitive benefits but also support each other and our community.

The Utilization Management Care Coordinator plays a crucial role within the healthcare team, responsible for overseeing, communicating, and facilitating the clinical journey of patients. This position is accountable for a specific patient caseload, ensuring effective planning to manage length of stay, optimize resource utilization, and adhere to evidence-based practice standards and regulatory requirements in accordance with New Jersey nursing regulations.

Key Responsibilities

A typical day for a Utilization Management Care Coordinator at Hackensack Meridian Health may involve:

  • Adhering to departmental processes for utilization review, including admission assessments, denial reviews, and communication with insurance providers.
  • Evaluating medical records for inpatient admissions to verify the presence of necessary documentation.
  • Collecting required records as mandated by payer agencies and initiating physician advisor reviews for questionable admissions.
  • Conducting chart assessments to determine the appropriateness of admissions and ongoing hospital stays based on clinical criteria.
  • Referring cases that do not meet criteria to the physician advisor or designated vendor for further evaluation.
  • Actively participating in relevant committees, workgroups, and meetings.
  • Identifying and referring quality concerns to the Quality Management Program.
  • Engaging in multidisciplinary rounds specific to assigned units.
  • Timely addressing issues that affect discharge and length of stay.
  • Performing necessary reassessments and evaluating progress against care objectives, adjusting plans as needed.
  • Collaborating with all members of the multidisciplinary team to support goals related to length of stay reduction and observation management.
  • Providing essential CMS documents to patients and their families in accordance with regulatory guidelines.
  • Maintaining annual competencies and completing required training and continuing education in relevant platforms.

Qualifications

Education, Knowledge, Skills, and Abilities Required:

  • Bachelor of Science in Nursing (BSN) or in progress, with a commitment to obtain within three years of hire.
  • Strong decision-making abilities, creativity in problem-solving, and effective leadership skills.
  • Excellent verbal, written, and presentation communication skills.
  • Moderate to advanced computer proficiency.
  • Familiarity with hospital and community resources, as well as utilization management practices.

Licenses and Certifications Required:

  • New Jersey State Professional Registered Nurse License.
  • AHA Basic Health Care Life Support HCP Certification.

Preferred Licenses and Certifications:

  • Certified Case Manager (CCM), Certified Clinical Medical Assistant (CCMA), or certification from the American Case Management Association (ACMA) is strongly preferred.

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