RN Utilization Review: Quality & Cost Optimization

Capital Health; Trenton, Northern (NJ, KY); Hybrid; USD 85,000 - 110,000; Full time

Benefits offered by this job

Medical Plan

Prescription drug coverage & In-HouseE

Dental Plan

Vision Plan

Retirement Savings Plan

Paid Time-Off Program

Job summary

Capital Health seeks an Utilization Review RN to conduct admission and ongoing utilization reviews, coordinating with physicians, payers and the care team to ensure appropriate level of care while promoting quality and cost efficiency.

The role requires an RN with an associate degree and UR or discharge planning experience; CM/CPHQ credentials are preferred. Strong collaboration and knowledge of CMS/MCG guidelines are essential.

Qualifications

• Associate's degree in Nursing required; NJ-licensed RN.
• Preferred certifications: CPHQ, CCM or CPUR.
• Experience: 3 years clinical nursing or 2 years in quality management, UR or discharge planning.

Responsibilities

• Perform utilization review and concurrent/retrospective reviews.
• Assess patient treatment plans and authorize appropriate level of care.
• Collaborate with care team and payers to optimize resource use.

Skills

Clinical nursing

Quality management

Utilization review

Discharge planning

Education

Associate's degree in Nursing

CPHQ

CCM

CPUR

Tools

UR software

EMR

Microsoft Office

Job description

Capital Health seeks an Utilization Review RN to conduct admission and ongoing utilization reviews, coordinating with physicians, payers and the care team to ensure appropriate level of care while promoting quality and cost efficiency.

The role requires an RN with an associate degree and UR or discharge planning experience; CM/CPHQ credentials are preferred. Strong collaboration and knowledge of CMS/MCG guidelines are essential.