Utilization Management RN - Medical Management Department
CarePoint Health - Jersey City, NJ

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Job Description:
This position is responsible for performing RN duties using established Milliman/MCG/CareWebQI guidelines to ensure appropriate level of care, providing authorizations of services & planning the transition of care across the continuum. He/She will perform duties & types of care management as assigned.

Primary Responsibilities (including but not limited to):

  • Assess member’s clinical need against established guidelines and/or standards to ensure that the level of care and length of stay are medically appropriate.
  • Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided.
  • Monitors and coordinates services rendered outside of the network, as well as outside the local area; negotiating fees for such services as appropriate. Coordinates with member, family, physician, hospital and other providers with respect to the appropriateness of care from diagnosis to outcome.
  • Coordinates the delivery of high quality, cost effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care.
  • Monitor’s member’s medical care activities, regardless of the site of service and outcomes for appropriateness and effectiveness.
  • Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided.
  • Encourages member participation and compliance in the care management disease efforts.
  • Accurately & comprehensively documents based on standards of practice and current organization policies.
  • Interacts and communicates with interdisciplinary teams either telephonically and/or in person striving for continuity & efficiency as the member is managed along the continuum of care.
  • Understands & practices fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes.
  • Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.
  • Completes other assigned functions as requested.

Job Qualifications:

  • BSN required
  • Current, unrestricted NJ RN license required
  • 2-3 years experience in a hospital setting, acute care, direct care experience OR experience as a case manager, care coordinator, utilization review/management, discharge planner; as well as prior telephonic Case Manager or UM RN for another insurance company required.
  • Prior experience in managed care organizations a plus.
  • Computer proficiency including the ability to type and talk at the same time, navigating a Windows environment required.
  • Prior experience with EMRs, case management, utilization review, care coordination, & discharge planning software tools a plus.
  • Working, proficient knowledge of Milliman/MCG/CarWebQI preferred.
  • Basic knowledge of health care contracts, benefit eligibility requirements, hospital structure & payment systems preferred.
  • Strong organizational skills, the ability to multitask in a constantly changing environment will be the keys to success.
  • Strong case management, care coordination & discharge planning in insurance, acute or sub acute setting a plus.
  • Ability to work autonomously yet be a part of the Medical management team is crucial.
  • Effective interpersonal and organizational skills a must

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With a focus on preventive medicine, healthcare education, and disease management, CarePoint Health provides patients with 360 Degree...