Utilization Management Care Coordinator, RN

2 weeks ago


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

Overview

At Hackensack Meridian Health, our workforce is integral to our mission of enhancing patient health and well-being. We prioritize a culture of collaboration and connection, ensuring that our employees thrive while delivering exceptional care to our community.

The Utilization Management Care Coordinator plays a vital role within the healthcare team, tasked with the coordination, communication, and facilitation of the clinical journey of patients. This position is accountable for managing a specific patient caseload, focusing on optimizing length of stay, efficient resource utilization, and adherence to evidence-based practices and regulatory standards.

Key Responsibilities

A typical day for a Utilization Management Care Coordinator may involve:

  • Adhering to departmental protocols for utilization review, including conducting admission reviews, managing denials, and overseeing continued stay evaluations.
  • Reviewing medical records for inpatient admissions to ensure all necessary documentation is available.
  • Gathering required records for payer agencies and initiating reviews by physician advisors for questionable admissions.
  • Conducting chart assessments to verify the appropriateness of admissions and ongoing hospital stays, applying relevant clinical criteria.
  • Referring cases that do not meet established criteria to the physician advisor or designated vendor for further evaluation.
  • Actively participating in relevant committees, workgroups, and meetings.
  • Identifying and escalating quality concerns to the Quality Management Program.
  • Engaging in multidisciplinary rounds specific to assigned units.
  • Addressing issues affecting discharge and length of stay promptly.
  • Conducting reassessments and evaluating progress against care objectives, adjusting plans as necessary.
  • Collaborating with multidisciplinary team members to support goals related to length of stay reduction and observation management.
  • Providing necessary CMS documentation to patients and their families in accordance with regulatory guidelines.
  • Maintaining annual competencies and completing ongoing training and education in relevant platforms.

Qualifications

Education, Knowledge, Skills, and Abilities Required:

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

Licenses and Certifications Required:

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

Preferred Licenses and Certifications:

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


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