Job DescriptionUtilization Reviewer (RN) - Emergency DepartmentAtlantic Health System - Newton, Hackettstown & Chilton Medical CenterFull-Time | Days | Monday-Friday | 8:00 AM - 4:00 PMThe Utilization Reviewer is responsible for conducting real-time medical necessity reviews and level-of-care determinations for patients presenting to the Emergency Department. This role serves as a key liaison between clinical teams and utilization management to ensure appropriate patient status assignment, regulatory compliance, and optimal patient throughput.
Responsibilities:
- Perform concurrent medical necessity reviews for Emergency Department patients utilizing MCG and/or InterQual criteria.
- Evaluate admission, observation, and level-of-care determinations in accordance with CMS, payer, and organizational guidelines.
- Collaborate with Emergency Department physicians, hospitalists, physician advisors, and care management teams to support timely patient placement decisions.
- Provide education and guidance regarding CMS Observation Rules, Two-Midnight Rule, and documentation requirements.
- Identify potential denial risks and compliance concerns and escalate as appropriate.
- Communicate patient status determinations and pertinent clinical information to inpatient Utilization Review staff for continuity of care.
- Participate in departmental quality initiatives, data collection, reporting, and performance improvement activities related to utilization management and patient throughput.
- Maintain current knowledge of regulatory and payer requirements impacting utilization review practices.
QualificationsRequired:
- Graduate of an accredited School of Nursing.
- Current New Jersey Registered Nurse (RN) License in good standing.
- Strong clinical assessment and critical thinking skills.
- Excellent communication and interdisciplinary collaboration abilities.
Preferred:
- Bachelor of Science in Nursing (BSN).
- Previous Case Management, Utilization Review, or Care Coordination experience.
- Experience utilizing MCG and/or InterQual criteria.
- Knowledge of CMS regulations, Observation Status requirements, and Utilization Management principles.
- Prior Emergency Department, Acute Care, Case Management, or Clinical Documentation experience.
Atlantic Health offers a competitive and comprehensive Total Rewards package that supports the health, financial security, and well-being of all team members. Offerings vary based on role level (Team Member, Director, Executive). Below is a general summary, with role-specific enhancements highlighted:
Team Member Benefits
- Medical, Dental, Vision, Prescription Coverage (22.5 hours per week or above for full-time and part-time team members)
- Life & AD&D Insurance.
- Short-Term and Long-Term Disability (with options to supplement)
- 403(b) Retirement Plan: Employer match, additional non-elective contribution
- PTO & Paid Sick Leave
- Tuition Assistance, Advancement & Academic Advising
- Parental, Adoption, Surrogacy Leave
- Backup and On-Site Childcare
- Well-Being Rewards
- Employee Assistance Program (EAP)
- Fertility Benefits, Healthy Pregnancy Program
- Flexible Spending & Commuter Accounts
- Pet, Home & Auto, Identity Theft and Legal Insurance
Note: In Compliance with the NJ Pay Transparency Act (effective Sunday, June 1, 2025), all job postings will include the hourly wage or salary (or a range), as well as this summary of benefits. Final compensation and benefit eligibility may vary by role and employment status and will be confirmed at the time of offer.
