Registered Nurse - Utilization Management - Per Diem

Position Summary Perform the Registered Nurse Utilization Review for an assigned patient population, including analyzing clinical data to determine appropriate level of care, ensuring medical necessity, and coordinating authorizations with insurance payers. Work closely with Physician Advisors to resolve documentation and status mismatches, follow up on provider decisions, and maintain regulatory compliance for government payers. Translate clinical findings into accurate accounting data to enable clean, compliant, and timely claims. Support system‑wide improvement initiatives and participate in the Utilization Review Committee. Responsibilities Analyze clinical information received to facilitate authorization from insurance providers and maximize reimbursement by preventing denials. Work closely with Physician Advisors (PAs) to confirm status and level‑of‑care mismatches and address provider documentation concerns. Ensure compliance with payer contracts, admission notification, and clinical review requirements for government payers. Maintain accurate insurance information in the system and ensure timely claim processing. Notify clinical teams and Patient Accounting of denial issues and changes in insurance information. Support hospital and medical staff improvement initiatives to enhance performance. Participate in UR Committee work as requested. Qualifications Bachelor’s degree in nursing; graduate of an accredited nursing school required. Current Registered Nurse license in the State of New Jersey (or multi‑state license). Effective Jan 2026: MCG (Milliman Clinical Guideline) certification required within 2 years of hire or transfer. Current incumbents must obtain MCG by1/1/2027. BLS certification required within 6 months of hire or transfer. Prior utilization / insurance case management experience preferred; experience with MCG/InterQual, HEDIS, CDI, or quality review preferred. Recent acute‑care medical‑surgical nursing experience preferred. Proficiency in Word, Excel formatting; clinical application proficiency at time of hire (training within 30–60 days). Performance Expectations Demonstrate technical competencies as established in the Assessment and Evaluation Tool. Work Environment Desk/computer work majority of the time, with occasional standing, walking, and lifting up to 20 pounds. Reporting Relationship Reports to department leadership. Benefits Generous paid time off (PTO) Medical, prescription drug, dental and vision insurance Retirement plans with employer contributions Short‑term and long‑term disability coverage Life and accidental death & dismemberment insurance Tuition reimbursement Flexible spending accounts (FSAs) for healthcare and dependent care Wellness programs Voluntary benefits, including pet insurance and more Benefits offerings may vary by position and are subject to eligibility requirements. #J-18808-Ljbffr