Registered Nurse - Utilization Management - Full Time

AtlantiCare; Egg Harbor Township (NJ); On-site; USD 85,000 - 110,000; Full time

Benefits offered by this job

Generous PTO

Medical Insurance

Retirement Plan

Disability Coverage

Life Insurance

Tuition Reimbursement

FSAs

Wellness Programs

Job summary

AtlantiCare in New Jersey seeks an RN for Utilization Management to analyze clinical information, determine the appropriate level of care, and submit reviews to insurers for authorization and reimbursement. The role relies on MCG guidelines and requires diligent documentation and coordination with Physician Advisors to address any status or care level discrepancies.

Candidates should have a nursing degree, NJ licensure, and a preference for Utilization/Coding certification.

Qualifications

• RN with degree from an accredited nursing program.
• Bachelor's in nursing required.
• Utilization/Coding certification preferred or in process.
• Knowledge of payer contracting and clinical review requirements.

Responsibilities

• Review clinical information to determine appropriate level of care and submit reviews to insurers.
• Utilize MCG criteria to assess medical necessity and patient status.
• Collaborate with Physician Advisors to resolve status mismatches and documentation concerns.
• Ensure accurate insurance data entry for clean, timely claim processing.
• Participate in UR Committee work and system-wide performance improvement initiatives.

Skills

Utilization Management

MCG/InterQual

HEDIS

Clinical Documentation

Word & Excel

Education

Bachelor's in Nursing

Graduate of accredited nursing program

Utilization/Coding certification preferred

Tools

MCG/InterQual

Clinical Applications

Microsoft Word/Excel

Job description

JOB DESCRIPTION

nalyzes clinical information received to facilitate authorization from insurance providers, maximize reimbursement by preventing denials, and ensures clinical data is sufficient to obtain an authorization. The RN works closely with Physician Advisors (PAs) to confirm that status and level-of-care mismatches, along with provider documentation concerns, are thoroughly reviewed and addressed, including follow-up on final decisions and peer-to-peer discussion outcomes as required. 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 RN 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 to result in clean, compliant, and timely claim processing. 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 RN supports system-wide improvement initiatives within the hospitals and the medical staff structure to ensure effective and timely performance improvement. This role Participates in UR Committee work as requested.

Qualifications

The RN Utilization Management 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 RN utilizes Evidenced Based ""MCG"" criteria/guidelines and other approved Atlanticare applications to assess and document the medical necessity and appropriate patient status/level of care determination. This position analyzes clinical information received to facilitate authorization from insurance providers, maximize reimbursement by preventing denials, and ensures clinical data is sufficient to obtain an authorization. The RN works closely with Physician Advisors (PAs) to confirm that status and level-of-care mismatches, along with provider documentation concerns, are thoroughly reviewed and addressed, including follow-up on final decisions and peer-to-peer discussion outcomes as required. 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 RN 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 to result in clean, compliant, and timely claim processing. 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 RN supports system-wide improvement initiatives within the hospitals and the medical staff structure to ensure effective and timely performance improvement. This role Participates in UR Committee work as requested.

EDUCATION

Graduate of an accredited school of nursing required. Bachelor's in nursing Required. Utilization/Coding certification preferred or in process.

License/Certification

Current licensure as a Registered Nurse in the State of New Jersey or current multi state license required.

Effective Jan 2026: Current MCG (Milliman Clinical Guideline) certification required within 2 years of hire or transfer. Current incumbents must obtain MCG by 1/1/2027.

American Heart Association BLS certification required within 6 months of hire or transfer. Current incumbents must obtain BLS by 6/30/2026.

EXPERIENCE

Prior Utilization/insurance case management experience Preferred. Experience on MCG/InterQual, HEDIS, CDI or Quality review preferred. Recent acute care Medical-Surgical nursing experience preferred. Proficient in using common computer software applications preferred (Word, Excel formatting). 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.

About Us

Total Rewards at AtlantiCare

Benefits

• Generous Paid Time Off (PTO)
• Medical, Prescription Drug, Dental & Vision Insurance
• Retirement Plans with employer contributions
• Short-Term & Long-Term Disability Coverage
• Life & Accidental Death & Dismemberment Insurance
• Tuition Reimbursement to support your educational goals
• Flexible Spending Accounts (FSAs) for healthcare and dependent care
• Wellness Programs to help you thrive
• Voluntary Benefits, including Pet Insurance and more

Benefits offerings may vary based on position and are subject to eligibility requirements.

Join a team that values your well-being and invests in your future.

Pay Transparency

In order to support the Fair Compensation Strategy by the US Govt., HR Dept., clients are required to adhere to "Pay Transparency Law" in impacted states, which mandate employers to list salary ranges in job advertisements and promotions.

AtlantiCare is an Equal Opportunity Employer