Utilization Review RN: Care Optimization & Payer

capitalhealth; Pennington (NJ); On-site; USD 54,000 - 70,000; Full time

Job summary

Capital Health seeks an experienced registered nurse to perform utilization management and discharge planning tasks. You will review patient charts, coordinate admissions, and work with payers to ensure efficient and cost-effective care while maintaining high-quality outcomes.

Requires a NJ RN license, an associate degree in nursing, and 5+ years of nursing with 3+ years in quality management or utilization review. Familiarity with CMS guidelines is essential for success in this role.

Qualifications

• Associate's degree in nursing from an accredited program.
• Five years' clinical nursing plus three years in quality management/utilization review or discharge planning.
• Registered Nurse license in NJ; CPHQ/CCM/CPUR preferred.

Responsibilities

• Perform chart reviews to assess quality, timeliness and appropriateness of care.
• Conduct admission reviews for Medicare/Medicaid and other payers to determine inpatient vs observation needs.
• Collect and analyze clinical data for continued stay utilization with payers daily.
• Adhere to CMS guidelines for utilization reviews and coordinate with physician advisors.
• Identify strategies to reduce length of stay and resource use.
• Collaborate with care teams to resolve barriers to progression of care.

Skills

Clinical nursing experience

Quality management

Utilization review

Discharge planning

Education

Associate's degree in nursing

Job description

Capital Health seeks an experienced registered nurse to perform utilization management and discharge planning tasks. You will review patient charts, coordinate admissions, and work with payers to ensure efficient and cost-effective care while maintaining high-quality outcomes.

Requires a NJ RN license, an associate degree in nursing, and 5+ years of nursing with 3+ years in quality management or utilization review. Familiarity with CMS guidelines is essential for success in this role.