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Clinical Utilization Review Nurse

2 months ago

Secaucus, New Jersey, United States Medix Full time
Medix is seeking a dedicated Utilization Review Nurse/Care Manager to join a prominent Healthcare system in New Jersey. This facility is a 200-bed institution with a fluctuating inpatient census, including ER and ICU services. The role involves managing clinical review submissions that vary daily, with an expectation to complete a minimum of 7-8 clinical reviews using established criteria each day. We are looking for Registered Nurses with a robust inpatient clinical background or experience in Care Management and Utilization Review. The MCG guidelines will be utilized for review criteria.

Work Schedule - Monday to Friday (8:30 AM - 4:30 PM)

Position Overview

The Registered Nurse will be responsible for providing case management and utilization review, along with routine discharge planning services for patients and their families. The goal is to facilitate safe and timely discharges, enhance the benefits of medical care, ensure hospital reimbursement, provide cost-effective acute care, and maintain continuity of care.

Key Responsibilities
  • Conducts comprehensive reviews of all patient charts within 24 hours of admission to evaluate the appropriateness of admission, intensity of service, and potential discharge needs.
  • Engages with insurance providers for admission and continued stay reviews as per contractual obligations to certify patient stays.
  • Certifies or denies all non-managed care cases daily, with denied cases referred to the Physician Advisor.
  • Participates in Interdisciplinary Rounds to review and facilitate the patient's care plan.
  • Coordinates effectively with ancillary departments and attending physicians to ensure timely care provision, reduce length of stay, and facilitate appropriate treatment and discharge.
Qualifications
  • Current Registered Nurse license in New Jersey.
  • Bachelor of Science in Nursing from an accredited institution.
  • A minimum of two years of direct patient care experience in an acute care hospital setting.
  • Familiarity with Medicaid, Medicare, Managed Care Review, and related communication and documentation requirements.
  • Understanding of Utilization Review criteria, including Interqual and/or Milliman.