Utilization Review RN: Optimize Care & Costs

Capital Health Screening Centre; Pennington (NJ); On-site; USD 54,000 - 70,000; Full time

Benefits offered by this job

Medical Plan

Prescription drug coverage

Dental Plan

Vision Plan

Flexible Spending Account (FSA)

Retirement Savings Plan

AD&D Insurance

Long/Short Term Disability

Job summary

Capital Health seeks an experienced Registered Nurse to lead utilization management and discharge planning efforts. You will review admissions, perform concurrent and retrospective utilization reviews, and collaborate with payers and care teams to optimize resources while preserving patient care quality.

Responsibilities include coaching on level-of-care determinations, staying current with CMS guidelines, and actively participating in daily huddles and performance improvement initiatives at

Qualifications

• RN with an Associate's degree and NJ RN licensure.
• 5 years nursing plus 3 years in quality management/utilization review or discharge planning.
• Proficient with UR software, EMR and MS Office.

Responsibilities

• Perform chart reviews to assess quality, timeliness and appropriateness of care.
• Conduct admission reviews for Medicare/Medicaid and private payers for care level appropriateness.
• Perform concurrent and retrospective reviews with payers according to guidelines and CMS requirements.
• Identify strategies to reduce length of stay and resource use while maintaining care quality.
• Coach admitting physicians on accurate level of care determinations at hospital entry.
• Stay updated on regulatory changes affecting delivery or reimbursement of acute care services.
• Apply hospital guidelines like HINN and LRD letters as required.
• Record progression of care barriers and participate in problem solving with care teams.
• Promote evidence-based protocols and order sets to improve outcomes and reduce costs.
• Document utilization activities thoroughly in the system and participate in daily huddles and handoffs.

Skills

UR software

EMR

Microsoft Office

Education

Associate's degree in nursing

CPHQ/CCM/CPUR preferred

Job description

Capital Health seeks an experienced Registered Nurse to lead utilization management and discharge planning efforts. You will review admissions, perform concurrent and retrospective utilization reviews, and collaborate with payers and care teams to optimize resources while preserving patient care quality.

Responsibilities include coaching on level-of-care determinations, staying current with CMS guidelines, and actively participating in daily huddles and performance improvement initiatives at