Registered Nurse Case Management Specialist

2 weeks ago

Trenton, New Jersey, United States NJM Insurance Group Full time

NJM Insurance Group is seeking a dedicated Registered Nurse Case Management Specialist to ensure that claimants receive exceptional, cost-efficient medical care leading to favorable outcomes. The ideal candidate will be focused on results and will engage in various aspects of utilization management, including case management interventions, precertification, concurrent reviews, and retrospective evaluations.

This role will involve some travel. The official title for this position is Medical Management Coordinator/Field Nurse Case Manager.

Key Responsibilities:

  • Deliver comprehensive Case Management services to a caseload of approximately 40-50 claimants, encompassing thorough assessments, strategic planning, implementation, and overall evaluation of individual needs.
  • Collaborate effectively with treatment providers to facilitate rehabilitation.
  • Analyze clinical information and conduct utilization management, both concurrent and retrospective, using established evidence-based clinical guidelines to assess treatment plans and manage inpatient lengths of stay.
  • Evaluate precertification/preauthorization requests for medical necessity, ensuring that treatments align with established guidelines, medical policies, and/or medical evidence. Cases that do not meet these guidelines will be referred to the Medical Director for further assessment.
  • Maintain precise records of all communications and interventions, including documentation within the claims system.
  • Engage in and support initiatives related to medical management projects.
  • Monitor utilization reports to ensure compliance and identify emerging trends.
  • Assist in the preparation of reports as necessary.
  • Support company and departmental Quality Assurance/Quality Improvement initiatives.
  • Stay updated with changes in regulations.
Required Qualifications and Experience:
  • Registered Nurse (RN) license in New Jersey.
  • A minimum of 3 years of experience is preferred in Med-Surg, critical care, clinical nursing, Utilization Management Review, and/or Hospital Bill Auditing.
  • Strong knowledge of professional nursing principles, clinical practice guidelines, and clinical interventions.
  • Experience with medical record reviews, medical terminology, and understanding of appropriate levels of healthcare and treatment modalities.
  • Excellent relationship management skills, with the ability to influence and mentor individuals at various experience levels.
  • Proven ability to problem-solve and navigate complex, multifaceted, and emotionally charged situations. Competence in negotiation, quality assurance, case management outcomes, and data analysis.
  • Willingness to travel within New Jersey.
  • Strong organizational skills, with the ability to prioritize tasks and delegate effectively.
  • Proficiency in Microsoft Office products and database programs, with strong data analysis and management skills.
Preferred Qualifications:
  • Experience in Workers Compensation and/or PIP.
  • Bachelor of Science in Nursing (BSN) from an accredited institution.
  • Experience with Utilization Review and Hospital Concurrent Review.
  • Familiarity with MCG/Millman, Official Disability Guidelines (ODG), and other evidence-based guidelines databases.

NJM is committed to being an equal opportunity employer, dedicated to attracting, retaining, and promoting a diverse and inclusive workforce that reflects the communities we serve.

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