POSITION SUMMARY
The RN Utilization Management is responsible for the overall Utilization Management process for assigned patient population. This includes reviewing clinical information to determine the appropriate level of care assignment, along with the completion and submission of reviews to insurance payers with appropriate follow-up. The RN utilizes Evidenced Based "MCG" criteria/guidelines and other approved Atlanticare applications to assess and document the medical necessity and appropriate patient status/level of care determination. This position analyzes clinical information received to facilitate authorization from insurance providers, maximize reimbursement by preventing denials, and ensures clinical data is sufficient to obtain an authorization. The RN works closely with Physician Advisors (PAs) to confirm that status and level-of-care mismatches, along with provider documentation concerns, are thoroughly reviewed and addressed, including follow-up on final decisions and peer-to-peer discussion outcomes as required. This position ensures that the obligation for clinical review is met according to the payer contracts and validates the accuracy of insurance information in the system. The RN is knowledgeable of the payer contracting arrangements, admission notification and clinical review requirements, as well as the regulatory and compliance requirements for government payers regarding clinical reviews and medical necessity. This role ensures that appropriate and accurate information is placed into the patient accounting system to result in clean, compliant, and timely claim processing. This role also provides notification of denial issues and potential avoidance of a denial, along with changes in insurance information to all appropriate areas (e.g. clinical team, Patient Accounting). The RN supports system-wide improvement initiatives within the hospitals and the medical staff structure to ensure effective and timely performance improvement. This role Participates in UR Committee work as requested.
QUALIFICATIONS
EDUCATION: Graduate of an accredited school of nursing required. Bachelor's in nursing Required. Utilization/Coding certification preferred or in process.
LICENSE/CERTIFICATION:
Current licensure as a Registered Nurse in the State of New Jersey or current multi state license required.
Effective Jan 2026: Current MCG (Milliman Clinical Guideline) certification required within 2 years of hire or transfer. Current incumbents must obtain MCG by 1/1/2027.
American Heart Association BLS certification required within 6 months of hire or transfer. Current incumbents must obtain BLS by 6/30/2026.
EXPERIENCE: Prior Utilization/insurance case management experience Preferred. Experience on MCG/InterQual, HEDIS, CDI or Quality review preferred. Recent acute care Medical-Surgical nursing experience preferred. Proficient in using common computer software applications preferred (Word, Excel formatting). Proficiency in Clinical Applications preferred at time of hire; incumbents within position will be trained appropriately and then skill will be required for this position within 30-60 days from date of hire.
PERFORMANCE EXPECTATIONS
Demonstrates the technical competencies as established on the Assessment and Evaluation Tool.
WORK ENVIRONMENT
This position requires desk/computer work a majority of the time. There is some standing, walking and occasional lifting up to 20 pounds. The essential functions for this position are listed on the Assessment and Evaluation Tool.
REPORTING RELATIONSHIP
This position reports to department leadership.
The above statement reflect the general details considered necessary to describe the principle functions of the job as identified and shall not be considered as a detailed description of all work requirements that may be inherent in the position.
