Careers
10-34831

Registered Nurse Utilization Management Behavioral Health - Full Time

Location: Egg Harbor Twp, NJ  |  Position Status: Full Time  |  Position Shift: Days

TITLE: Utilization Management Nurse, Behavioral Health

                 

JOB CODE: #  7073

EXEMPT:

NON-EXEMPT:

DATE: 03/23

REVISED:

 

 

  • Graduate of an accredited school of nursing required.
  • Current licensure as a nurse in the state of New Jersey or compact licensed with New Jersey.

POSITION SUMMARY
The utilization management nurse, behavioral health 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 Utilization Management staff utilizes designated criteria/guidelines to determine and document the medical necessity and appropriate level of care. This position analyzes clinical information received to facilitate authorization from insurance providers, maximize reimbursement by preventing denials, and ensure clinical data is sufficient to obtain an authorization. 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 Utilization Management staff 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 for processing of payment. 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 Utilization Management staff supports Behavioral Health service line improvement initiatives within ambulatory, 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: RN or LPN. Bachelor's in nursing preferred. Case management certification preferred.
  • LICENSE/CERTIFICATION: Current licensure as a nurse in the state of New Jersey or compact licensed with New Jersey.
  • EXPERIENCE: Case management/insurance case management experience preferred. 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 reflects the general details considered necessary to describe the principal 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.
AtlantiCare is an equal opportunity employer that takes affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status or disability.
Rebecca Leeds
Applicants only. We are not accepting inquiries or solicitations from recruiters/search firms.

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We believe that healthcare should be a rewarding career. That’s why we offer excellent compensation, exceptional health and wellness benefits, and internal resources and programs to support professional growth for our team members. Here, you’ll find everything you need to pursue your calling of caring for others, knowing that you’re working for an organization dedicated to your overall well-being.

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