OverviewOur team members are the heart of what makes us better. At Hackensack MeridianHealthwe help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning.It’salso about how we support one another and how we show up for our community. Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change.The Case Management Care Coordinator, Utilization Management is a member of the healthcare team and is responsible for coordinating, communicating, and facilitating the clinical progression of the patient's treatment. Accountable for a designated patient caseload; the Care Coordinator, Utilization Management plans effectively in order to manage length of stay, promote efficient utilization of resources and ensure that care meets evidence-based practice standards and regulatory/payor requirements and follows the state of New Jersey regulations for Nursing.Responsibilities
Follows departmental workflows for utilization review activities including admission reviews, admission denials, continued stay reviews, continued stay denials, termination of benefits, communication of information to insurance company, billing certifications, concurrent managed care denial appeals and retrospective medical record utilization reviews.
Obtains and evaluates medical records for inpatient admissions to determine if required documentation is present.
Obtains appropriate records as required by payer agencies and initiates physician advisor's review as necessary for unwarranted admissions.
Performs chart reviews for appropriateness of admission and continued hospital stay applying appropriate clinical criteria. Performs admission review within 24 hours or the first business day.
Refers cases not meeting criteria to the physician advisor or designated vendor for determination and action.
Participates actively on appropriate committees, workgroups, and or meetings.
Identifies and refers quality issues for review to the Quality Management Program.
Participates in multidisciplinary rounds, specific to assigned units. Brings forth issues which impact discharge and length of stay in a timely manner.
Performs appropriate reassessments and evaluates progress against care goals and the plan of care and revises plans, as needed.
Collaborates with all members of the multidisciplinary team to support length of stay reduction and observation management goals.
Provides appropriate CMS documents to the patient and family/support person as per regulatory guidelines (ie., Important Message 4 to 48 hours prior to discharge, appeal and HINN notices)
Maintains annual competencies and completes training and continuing education in applicable platforms. (Epic, Xsolis Cortex, Enterprise Analytics, Google Suites).
Other duties and/or projects as assigned.
Adheres to HMH Organizational competencies and standards of behavior.
QualificationsEducation, Knowledge, Skills and Abilities Required:
BSN or BSN in progress and/or willing to acquire within 3 years of hire or transfer into the position
Effective decision-making skills, demonstration of creativity in problem-solving, and influential leadership skills
Excellent verbal, written and presentation skills
Moderate to expert computer skills
Familiar with hospital resources, community resources, and utilization management
Licenses and Certifications Required:
NJ State Professional Registered Nurse License
AHA Basic Health Care Life Support HCP Certification
Licenses and Certifications Preferred:
Certified Case Manager (CCM), Certified Clinical Medical Assistant (CCMA), or American Case Management Association (ACMA) certification strongly preferred
Department Utilization ReviewSite Hackensack University Med CntrJob Location US-NJ-HackensackPosition Type Per DiemStandard Hours Per Week 8Shift NightShift Hours 7 p.m. - 7:30 a.m.Weekend Work Every Other WeekendOn Call Work No On-Call RequiredHoliday Work As Needed