The Care Management, Care Coordinator, Utilization Management is a member of the healthcare team and is responsible for coordinating, communicating, and facilitating the clinical progression of the patient¿s treatment. Accountable for a designated patient caseload; the Care Coordinator, Utilization Management plans effectively in order to manage length of stay, promote efficient utilization of resources and ensure that care meets evidence-based practice standards and regulatory/payor requirements and follows the state of New Jersey regulations for Nursing.

• Follows departmental workflows for utilization review activities including admission reviews, admission denials, continued stay reviews, continued stay denials, termination of benefits, communication of information to insurance company, billing certifications, concurrent managed care denial appeals and retrospective medical record utilization reviews.
• Obtains and evaluates medical records for inpatient admissions to determine if required documentation is present.
• Obtains appropriate records as required by payer agencies and initiates physician advisor's review as necessary for unwarranted admissions.
• Performs chart reviews for appropriateness of admission and continued hospital stay applying appropriate clinical criteria. Performs admission review within 24 hours or the first business day.
• Refers cases not meeting criteria to the physician advisor or designated vendor for determination and action.
• Participates actively on appropriate committees, workgroups, and or meetings.
• Identifies and refers quality issues for review to the Quality Management Program.
• Participates in multidisciplinary rounds, specific to assigned units. Brings forth issues which impact discharge and length of stay in a timely manner.
• Performs appropriate reassessments and evaluates progress against care goals and the plan of care and revises plans, as needed
• Collaborates with all members of the multidisciplinary team to support length of stay reduction and observation management goals.
• Provides appropriate CMS documents to the patient and family/support person as per regulatory guidelines (ie., Important Message 4 to 48 hours prior to discharge, appeal and HINN notices)
• Maintains annual competencies and completes training and continuing education in applicable platforms. (Epic, Xsolis Cortex, Enterprise Analytics, Google Suites)
• Adheres to the Medical Center¿s Organization Competencies and the Standard of Behavior.
• Other duties as assigned

Education, Knowledge, Skills And Abilities Required

• BSN or BSN in progress and/or willing to acquire within 3 years of hire or transfer into the position.
• Effective decision-making skills, demonstration of creativity in problem-solving, and influential leadership skills.
• Excellent verbal, written and presentation skills
• Moderate to expert computer skills
• Familiar with hospital resources, community resources, and utilization management

Licenses And Certifications Required

• NJ State Professional Registered Nurse License.
• AHA Basic Health Care Life Support HCP Certification.
• Care Management certification by a nationally recognized organization within 1 year.

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