Utilization Review RN: Denials & Appeals Specialist

Capital Health (US); Trenton (NJ); On-site; USD 87,000 - 120,000; Full time

Benefits offered by this job

Medical Plan

Prescription drug coverage

Dental Plan

Vision Plan

FSA

Job summary

Capital Health in New Jersey seeks an experienced RN to perform Utilization Review for inpatient care, managing denials, appeals, and audits to maximize reimbursement and compliance.

Requires RN license in NJ, 5 years nursing, 3 years in case management including UR, discharge planning and outcomes, plus CMS guidelines knowledge and UR/EMR software proficiency. 40-hour week, competitive benefits.

Qualifications

• Graduation from an accredited School of Registered Nursing.
• Five years' nursing experience; three years in case management including utilization review, discharge planning, outcomes management, assessment, care planning, and/or care coordination; inpatient denial appeal experience preferred.
• Registered Nurse - NJ
• Knowledge of CMS guidelines, payor guidelines, contractual rules, and applicable clinical guidelines.
• Proficient in Word, Excel, Outlook and other UR software and EMR software.

Responsibilities

• Monitors inpatient utilization process and ensures compliance with standards and payer contracts.
• Interfacing with HIM and billing to coordinate clinical components for appropriate reimbursement.
• Performs utilization review audits and supports the Utilization Committee with outcomes data.
• Maintains current knowledge of CMS, NJDHSS, DOBI, and QIO regulations related to managed care and utilization.
• Participates in regulatory readiness activities and develops departmental performance improvement projects.

Skills

Utilization review

Discharge planning

Care coordination

CMS guidelines knowledge

Education

Registered Nurse – NJ

Tools

UR software

EMR software

Word

Excel

Outlook

Job description

Capital Health in New Jersey seeks an experienced RN to perform Utilization Review for inpatient care, managing denials, appeals, and audits to maximize reimbursement and compliance.

Requires RN license in NJ, 5 years nursing, 3 years in case management including UR, discharge planning and outcomes, plus CMS guidelines knowledge and UR/EMR software proficiency. 40-hour week, competitive benefits.