Job Description1. Provides timely and thorough clinical information to insurance companies and other intermediaries to secure payer authorizations and avoid denials or reduction in level of care.
2. Performs daily surveillance of observation cases and works with PA discussing any barriers to progression of care or discharge.
3. Intervenes proactively to avoid denials or delays in authorization.
4. Actively communicates information to other CM team members and interdisciplinary teams regarding progress or payer issues related to continued hospitalization and post-acute service associated with the patients discharge plan.
5. Refers cases and issues to Physician Advisors or Designees in compliance with department procedures with timely follow up as indicated
6. Assists in identification and collection of avoidable days
7. Coordinates with the CM RN and/or CMA to identify and complete the process for CMS required patient notices.
8. Completes and documents utilization reviews, physician advisor referrals and other communications related to assigned cases in accordance with department policy and procedure.
9. Complies with the Condition of Code 44 process, CMS required patient notices and other regulatory requirements within the utilization management process.
10. Maintains proficiency in the application of organization selected clinical review criteria sets evidenced through IRR testing
QualificationsGraduate of an accredited school of nursing - required
BSN - preferred
Current RN license - required
Case Management - Preferred
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.
