Utilization Review RN: Case Management & Compliance

01 The Valley Hospital; Paramus (NJ); On-site; USD 69,000 - 86,000; Full time

Job summary

The Valley Hospital in Paramus, NJ seeks an Utilization Case Manager to perform concurrent utilization review, ensure medical necessity, and CMS compliance while collaborating with physicians and care coordination staff to support admission status decisions and optimize length of stay.

Required is a NJ RN license and a BSN; experience in case management or utilization review is strongly preferred, with focus on regulatory requirements and payer guidelines.

Qualifications

• BSN in nursing required.
• Current RN license in New Jersey required.
• Experience in case management and/or utilization review strongly preferred.
• Knowledge of CMS, payer requirements, and reimbursement processes.

Responsibilities

• Performs concurrent utilization review to ensure appropriate level-of-care determinations, medical necessity, regulatory compliance, and resource utilization.
• Collaborates with physicians, payers, Physician Advisors, and care coordination staff to support admission status decisions and optimize length of stay.
• Serves as a resource on utilization management and reimbursement regulations while promoting quality patient outcomes.

Skills

Acute care nursing

Utilization review principles

Medical necessity criteria

MCG guidelines

CMS/Medicare/Medicaid requirements

Communication and collaboration

EMR systems

Case management software

Education

Bachelor's degree in nursing (BSN)

Tools

EMR systems

Case management software

Job description

The Valley Hospital in Paramus, NJ seeks an Utilization Case Manager to perform concurrent utilization review, ensure medical necessity, and CMS compliance while collaborating with physicians and care coordination staff to support admission status decisions and optimize length of stay.

Required is a NJ RN license and a BSN; experience in case management or utilization review is strongly preferred, with focus on regulatory requirements and payer guidelines.