RN Utilization Management: Drive Approvals & Care

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

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.