Utilization Review Case Manager, Care Coordination, Full Time, Day

Valley Medical Services Inc; Paramus (NJ); On-site; USD 69,000 - 86,000; Full time

Benefits offered by this job

Medical, Dental & Vision Discount (FT/

Group Term Life Insurance & AD&D (FT)

Flexible Spending Accounts

Commuter Benefit Plans

Paid Holidays & PTO

Retirement Plan

Tuition Assistance

Employee Assistance Program (EAP)

Wellness Center Membership Discount

Day Care Discounts

Job summary

The Valley Hospital-Paramus is seeking an Utilization Case Manager to perform concurrent utilization review, ensuring appropriate level-of-care determinations and regulatory compliance. You will collaborate with physicians, payers, and care coordination staff to support admission decisions and optimize length of stay.

Requirements include a BSN and an active NJ RN license; prior utilization review or case management experience is preferred.

Qualifications

• Bachelor's degree in nursing required.
• Current RN license in New Jersey required.
• Experience in case management and/or utilization review preferred.
• Knowledge of CMS, Medicare, Medicaid, and payer requirements.
• Strong communication and collaboration with physicians, payers, patients, families.
• Proficient in the use of electronic medical records and case management software.

Responsibilities

• Perform concurrent utilization review to ensure medical necessity.
• Collaborate with physicians, payers, and care teams to support admission decisions.
• Promote quality patient outcomes and regulatory compliance.
• Serve as resource on utilization management and reimbursement regulations.

Skills

Acute care nursing

Utilization review

CMS/ payer requirements

Physician collaboration

EMR systems

Case management software

Education

BSN in Nursing

Tools

EMR

Case management software

Job description

POSITION SUMMARY:

The Utilization Case Manager performs concurrent utilization review to ensure appropriate level-of-care determinations, medical necessity, regulatory compliance, and effective resource utilization. Collaborates with physicians, payers, Physician Advisors, and care coordination staff to support admission status decisions, prevent reimbursement denials, optimize length of stay, and ensure compliance with CMS and payer requirements. Serves as a resource on utilization management, medical necessity criteria, and reimbursement regulations while promoting quality patient outcomes and organizational performance.

EDUCATION:

Bachelor's degree (BSN) in nursing required.

EXPERIENCE:

Current Registered Nurse (RN) License in the State of New Jersey required. Experience in case management and/or utilization review experience strongly preferred.

SPECIAL SKILLS:

• Demonstrates knowledge of acute care nursing practice, utilization review principles, medical necessity criteria, MCG guidelines, and applicable CMS, Medicare, Medicaid, and commercial payer requirements.Understands healthcare documentation standards, reimbursement processes, and utilization management practices.


• Strong communication and collaboration skills when working with physicians, payers, patients, families, and interdisciplinary teams.


• Uses critical thinking, clinical reasoning, and analytical skills to evaluate medical necessity, interpret clinical documentation, and resolve utilization management concerns.


• Proficient in the use of electronic medical records and case management software.


• Manage multiple priorities in a fast-paced environment while maintaining accuracy and attention to detail.


• Interprets complex clinical and regulatory information, works effectively with diverse stakeholders, and remains professional and composed when addressing challenging situations, changing priorities, and reimbursement-related issues.

Job Location

The Valley Hospital-Paramus

Shift

Day (United States of America)

Benefits

• Medical/Prescription, Dental & Vision Discount Program (Full Time/Part Time Employees)


• Group Term Life Insurance and AD&D(Full Time Employees)


• Flexible Spending Accounts and Commuter Benefit Plans


• Supplemental Voluntary Benefits ( e.g. Short-term and Long-term Disability, Whole Life Insurance, Legal Support, etc.)


• 6 Paid Holidays, Paid Time Off (varies), Wellness Time Off, Extended Illness


• Retirement Plan


• Tuition Assistance


• Employee Assistance Program (EAP)


• Valley Health LifeStyles Fitness Center Membership Discount


• Day Care Discounts for Various Daycare Facilities

Salary

Joining Valley Health System means becoming part of a dedicated team that values the highest quality of care in a supportive environment. In our commitment to high performance and reliability, we encourage and recognize exceptional individual performance through our industry leading compensation practices including a starting salary and benefits in accordance with your role, experience, education, and licensure. Actual individual salaries vary depending on these factors. The salary listed does not include other forms of compensation or benefits.Pay Range: $50.18 - $62.73 (per hour)

EEO Statement

Valley Health System does not discriminate on the basis of ancestry, age, atypical hereditary cellular or blood trait, civil union status, color, creed, disability, domestic partnership, gender, gender identity or expression, familial status, genetic information, liability for service in the Armed Forces of the United States, marital status, medical condition or illness, mental or physical handicap, national origin, nationality, perceived disability, pregnancy, race, refusal to submit to genetic testing or make available results of such tests, religion, sex, sexual orientation, veteran’s status or any other protected basis, in accordance with all applicable Federal, State and Local laws. This applies to all areas of employment, including recruitment, hiring, training and development, promotion, transfer, termination, layoff, compensation, benefits, social and recreational programs, and all other conditions and privileges of employment.