Clinical Case Management Nurse

2 weeks ago


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

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

This role may involve some travel. The official title within NJM is Medical Management Coordinator/Field Nurse Case Manager.

Key Responsibilities:

  • Deliver Case Management services to a caseload of approximately 40-50 claimants, which encompasses: thorough assessment, strategic planning, implementation, and comprehensive evaluation of individual claimant requirements.
  • Collaborate with healthcare providers to facilitate rehabilitation efforts.
  • Analyze clinical data and execute utilization management, both concurrent and retrospective, utilizing 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 clinical evidence. Cases that do not meet the necessary criteria 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 required.
  • Support company and departmental Quality Assurance/Quality Improvement initiatives.
  • Stay informed about changes in regulations.
Required Qualifications and Experience:
  • Registered Nurse (RN) licensed in New Jersey.
  • A minimum of 3 years of experience preferred in: Med-Surg and critical care nursing, Utilization Management Review/Hospital concurrent reviews, and/or Hospital Bill Auditing for inappropriate charges, denials, and uncertified days.
  • In-depth knowledge of professional nursing principles, clinical practice guidelines, and clinical interventions.
  • Experience with medical record evaluations, medical terminology, appropriate levels of healthcare, treatment modalities, and healthcare delivery systems.
  • Excellent relationship management abilities, including the capacity to influence and mentor individuals with varying levels of experience.
  • Proven problem-solving skills to 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 applications and database management, along with data analysis capabilities.
Preferred Qualifications:
  • Experience in Workers Compensation and/or PIP.
  • Bachelor of Science in Nursing (BSN) from an accredited institution.
  • Experience with Utilization Review/Hospital Concurrent Review (monitoring hospital/rehabilitation stays for medical necessity and intensity of service).
  • Familiarity with MCG/Millman, Official Disability Guidelines (ODG), and/or other evidence-based guidelines databases.

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



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