Utilization Review Nurse - (RN) - Part Time - Benefit Eligible - Days

Overview

CentraState Healthcare System, headquartered in Freehold, New Jersey, is a leading nonprofit healthcare provider dedicated to serving the community. Its comprehensive network includes CentraState Medical Center, a community-focused hospital, along with an ambulatory campus, two senior living facilities, three free-standing community health pavilions, and a charitable foundation. As the third-largest employer in Monmouth County, CentraState has earned repeated recognition as a Great Place to Work-Certified™ company, reinforcing its reputation as an exceptional workplace.

 

CentraState Medical Center has an employment opportunity available for a Utilization Review Nurse. The Utilization Review RN (UR RN) applies professional nursing judgment and critical thinking skills to assess patients for appropriate levels of care and to mitigate potential denials. This role requires a strong knowledge of evidence-based clinical criteria and federal and state utilization management requirements. The UR RN identifies key clinical information to support hospital admissions and continued stays, collaborates with the care management team to optimize resource utilization, and secures payer approvals. The UR RN also reviews escalated cases that do not meet medical necessity prior to initiating secondary review.

Responsibilities

Responsibilities include, but are not limited to:

• Provides timely and thorough clinical information to insurance companies and other intermediaries to secure payer authorizations and avoid denials or reduction in level of care.
• Performs daily surveillance of observation cases and works with APNs and PA discussing any barriers to progression of care or discharge.
• Intervenes proactively to avoid denials or delays in authorization.
• Actively communicates information to other CM team members and interdisciplinary teams regarding progress or payer issues related to continued hospitalization and post-acute service associated with the patients discharge plan.
• Refers cases and issues to Physician Advisors or Designees in compliance with department procedures with timely follow up as indicated.
• Assists in identification and collection of avoidable days and management of the expected discharge date.
• Coordinates with the CM RN and/or CMA to identify and complete the process for CMS required patient notices.
• Completes and documents utilization reviews, physician advisor referrals and other communications related to assigned cases in accordance with department policy and procedure.
• Complies with the Condition of Code 44 process, CMS required patient notices and other regulatory requirements within the utilization management process.
• Maintains proficiency in the application of organization selected clinical review criteria sets evidenced through IRR testing
• Assists in facilitating and coordinating clinical progression of assigned patients

Other duties as assigned by management

Qualifications

• BSN or Bachelor’s Degree in related field or current enrollment in BSN or related Bachelor’s Degree program required.
• Prior clinical experience in care and management of hospitalized patients.
• Experience in acute care case management, preferred.
• Utilization review or case management training from a professional Case Management organization, preferred.
• RN license required/NJ.
• Case Management certification preferred.
• Excellent communication, negotiation, and conflict resolution skills
• Data and computer skills
• Knowledge of relevant and state utilization review and appeals requirements
• Rapid cycle change or clinical performance improvement expertise

About Us

CentraState Healthcare System, in partnership with Atlantic Health System, is a fully accredited, not-for-profit, community-based health system dedicated to providing comprehensive health services in central New Jersey. Beyond offering a wide range of advanced diagnostic and treatment options, CentraState is committed to being a valuable health partner, focusing on disease prevention, promoting healthy behaviors, and helping individuals of all ages live well.

 

Located in Freehold, CentraState includes a 284-bed acute-care hospital, a dynamic health and wellness campus, two award-winning senior living communities, a charitable foundation, and convenient satellite health pavilions. These pavilions offer primary care, specialty physician practices, and access to outpatient services such as lab work and physical therapy.

 

CentraState is proud to be among the less than two percent of hospitals nationwide to earn Magnet® designation for nursing excellence five times. Additionally, it has been recognized as a Great Place to Work-Ce