Inpatient Utilization Review RN – Denials & Appeals

Capital Health (US); Trenton (NJ); On-site; USD 86,000 - 120,000; Full time

Benefits offered by this job

Medical Plan

Prescription drug coverage

Dental Plan

Vision Plan

Flexible Spending Account (FSA)

Healthcare FSA

Retirement Savings and Investment Plan

Paid Time-Off Program

Job summary

Capital Health is seeking a Registered Nurse to perform utilization review for inpatient cases, manage denials, and coordinate appeals. The role requires extensive experience in case management including discharge planning and outcomes management.

The position includes collaboration with HIM and billing, adherence to CMS guidelines, and use of UR software and EMR systems. Strong analytical and documentation skills are essential.

Qualifications

• Graduation from an accredited School of Registered Nursing.
• Five years' experience in nursing.
• Three years' experience in case management including utilization review, discharge planning, outcomes management, assessment, care planning, and/or care coordination.

Responsibilities

• Perform Utilization Review functions for third party reimbursement, denials, appeals and clinical audits for inpatient cases.
• Ensure responsibility for Performance Improvement and Quality Improvement activities in the department.
• Prepare and submit appeals timely and manage the inpatient UR appeal process.
• Monitor inpatient utilization process and ensure it is performed adequately.
• Interface with HIM and billing to coordinate clinical components for appropriate reimbursement.

Skills

Utilization review

Discharge planning

Case management

CMS guidelines

EMR software

Education

RN nursing degree

Tools

Utilization review software

EMR software

Microsoft Word

Microsoft Excel

Microsoft Outlook

Job description

Capital Health is seeking a Registered Nurse to perform utilization review for inpatient cases, manage denials, and coordinate appeals. The role requires extensive experience in case management including discharge planning and outcomes management.

The position includes collaboration with HIM and billing, adherence to CMS guidelines, and use of UR software and EMR systems. Strong analytical and documentation skills are essential.