Utilization Coordinator RN - FT - RMC

Work Shift

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advance technology. Capital Health is a five-time Magnet-Recognized health system for nursing excellence and is comprised of 2 hospitals. Capital Health Medical Group is made up of more than 250 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Position Overview

SUMMARY (BASIC PURPOSE OF THE JOB)

Coordinates the Utilization Review function for Capital Health related to third party reimbursement, denials and appeals and clinical audits. Ensures responsibility for the Performance Improvement, Utilization Manager productivity, and Quality Improvement activities in the department. Ensures responsibility for all regulatory readiness and preparation activity in the department.

Minimum Requirements

Education: Graduation from an accredited School of Registered Nursing.

Experience: Five years of experience in nursing. Experience in case management field including utilization review, discharge planning, outcomes management, assessment, care planning, and/or care coordination.

Other Credentials:Registered Nurse - NJ

Knowledge and Skills:Knowledge of CMS guidelines, payor specific guidelines, contractual rules, and applicable clinical guidelines. Ability to interpret a variety of instructions furnished in written, oral, diagram or schedule form.

Special Training:Word Processing, Spreadsheet software. Ability to use electronic mail, AS 400 system and other Utilization Management software and patient information software.

Mental, Behavioral And Emotional Abilities

Usual Work Day:8 Hours

REPORTING RELATIONSHIPS

Does this position formally supervise employees? Yes

If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager.

Essential Functions

• Monitors the inpatient utilization process and ensures that the process is performed adequately on all inpatients in accordance with applicable standards, regulations and payer contracts.
• Manages the denial and appeal process for the department.
• Interfaces with the Health Information Management (HIM) and Patient Finance departments to coordinate clinical components to ensure appropriate reimbursement.
• Performs accurately chart and utilization review audits as directed.
• Supports the Capital Health Utilization Committee with analysis of clinical outcomes data.
• Exercises discretion and judgement to evaluate, develop and implement computer based data systems to support the utilization management and reporting functions. Prepares accurate and timely reports on all data collected as directed that demonstrates the effectiveness of the utilization program.
• Prepares for and maintains accurate records of utilization audits by payors and QIO.
• Maintains current and accurate knowledge of relevant CMS, NJDHSS, DOBI and QIO regulations related to managed care and utilization.
• Coordinates the training of staff in utilization management processes ensuring staff expertise and performance.
• Participates in Joint Commission (TJC) and other regulatory readiness and preparation activity, as directed.
• Develops departmental performance improvement projects.
• Manages the UM physician advisor program at Capital Health.
• Oversees the denial life cycle process for the department. Enters and updates denials into the UR software system.
• Reviews all denial entries daily for accuracy (Admission, Continuous Stay, Dropped Level of Care and Retrospective Audit). Corrections made when applicable.
• Reviews and updates denial status from pending and open denials (concurrent reconsideration and peer-to-peer review) to sending denials for formal appeals daily.
• Extracts denials from the UR software system and prepares them in a excel spreadsheet to be electronically submitted for retrospective appeal.
• Updates appeal status upon notification. Manages, reports and writes retrospective Medicaid Appeal Audit denials.
• Prepares and submits the written appeal to the auditing agency.
• Monitors, tracks, manages and completes the retrospective audit denial appeals process.
• Track denial life cycle tracking and monitoring using an excel electronic platform.
  
  

PHYSICAL DEMANDS AND WORK ENVIRONMENT

Frequent physical demands include: Sitting , Standing , Keyboard use/repetitive motion

Occasional physical demands include: Walking , Climbing (e.g., stairs or ladders) , Carry objects , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Squat/kneel/crawl , Wrist position deviation , Pinching/fine motor activities

Continuous Physical Demands Include

Lifting Floor to Waist 15 lbs. Lifting Waist Level and Above 10 lbs.

Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Color Discrimination, Minimal Depth Perception, Minimal Hearing

Anticipated Occupational Exposure Risks Include the following: Bloodborne Pathogens , Chemical , Airborne Communicable Disease

IND123

Offers are contingent upon successful completion of our onboarding process and pre-employment physical. Capital Health will require all applicants to have an annual flu vaccine prior to start date, with the exception of individuals with medical and religious exemptions.

"Company will never ask candidates for social security numbers or date of birth during application phase. If you are asked for this information online, you may be a target for identity theft."