Registered Nurse - Case Manager

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Registered Nurse - Case Manager

Contract to Hire: Hopewell, New Jersey, US

Salary Range: 33.00 - 34.00 | Per Hour

Job Code: 368986

End Date: 2026-05-27
Days Left: 0 days, 20 hours left

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Job Title: Clinical RN I - Utilization Management (Inpatient Case Management)

Job Location: Hopewell, New Jersey 08534 (Onsite)

Job Duration: 3 Months Contract

Pay Rate: $33.00 to $34.00/hr

Job Description:

Role Summary

• The Clinical RN I - Utilization Management (Inpatient Case Management) is responsible for conducting structured pre-pay and post-pay clinical documentation audits in alignment with state audit requirements and internal guidelines.
• This role involves reviewing clinical documentation, validating authorizations, and comparing cases against medical necessity criteria (MCG) to support payment integrity and compliance.
• The RN works within defined workflows and guidelines and does not make final medical necessity determinations independently, but escalates cases as required.

Key Responsibilities

1. Pre-Pay / Post-Pay Audit Execution

• Perform daily clinical documentation audits using the State Audit Process Guide
• Review claims from daily triage reports and process cases individually
• Access and evaluate claim documentation via ECM/DMS systems
• Review audit findings documented within case files

1. Clinical Documentation Review

• Assess clinical records for completeness and accuracy
• Validate authorizations using Care Radius
• Apply and compare MCG criteria with audit findings
• Attach relevant supporting clinical criteria for audit decisions

1. Audit Documentation & Tracking

• Document findings using standardized audit templates
• Clinical findings
• Ensure accurate and timely audit logs

1. Compliance & Quality Assurance

• Adhere to state regulations, internal policies, and confidentiality standards
• Identify documentation gaps and escalate as needed
• Maintain consistency and accuracy in audit processes

1. Collaboration & Communication

• Communicate audit findings with internal teams and leadership
• Participate in training, calibration sessions, and quality reviews
• Implement feedback to improve audit performance

Systems & Tools:

• Excel (Audit Tracker & Reporting)
• ECM / DMS (ITS) - document management
• Care Radius - authorization validation
• MCG - medical necessity guidelines
• Outlook / MS Teams - communication

Required Qualifications

• Active, unrestricted Registered Nurse (RN) license
• ASN or BSN degree
• Strong analytical and documentation skills
• Ability to follow structured workflows and apply clinical criteria

Preferred Qualifications

• Experience in pre-pay or post-pay audits
• Familiarity with MCG guidelines
• Experience with audit trackers and document systems
• Exposure to state or regulatory audits

The Company offers the following benefits for this position, subject to applicable eligibility requirements: medical insurance, dental insurance, vision insurance, 401(k) retirement plan, life insurance, long-term disability insurance, short-term disability insurance, paid parking/public transportation, paid time off, paid sick and safe time, hours of paid vacation time, weeks of paid parental leave, and paid holidays annually - as applicable.

Job Requirement

• Utilization Review Nurse
• Utilization Management Nurse
• UM Nurse
• Inpatient Case Manager (RN)
• RN Case Manager
• Clinical Case Manager
• Nurse Case Manager
• Clinical Review Nurse
• Clinical Documentation Review Nurse
• Clinical Documentation Specialist (RN)
• DRG Validation Nurse
• Clinical Auditor (RN)
• Nurse Auditor
• Audit Nurse
• Payment Integrity Nurse
• Quality Assurance Nurse (Clinical)
• Managed Care Nurse
• Health Plan Nurse
• Medical Review Nurse
• Care Management Nurse
• Prior Authorization Nurse
• Authorization Review Nurse
• Registered Nurse Case Manager
• Clinical Analyst (RN)
• Population Health Nurse
• Care Coordinator (RN)

Reach Out to a Recruiter

• Recruiter
• Email
• Phone
• Prince Singh
• View email address on click.appcast.io

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