RN Manager Utilization

Position Summary:

Responsible for development and implementation of hospital “wide system / processes for Utilization Management, Denials /Appeals Management, Resource / LOS Management, pre-certification, authorization, and value-based programs. Accountable for directing the day-to-day operations for Concurrent Utilization Review processes for Medicare, Medicaid, Managed Care and Commercial Payors, Oversight of all inpatient Denials and Appeals activity i.e. Medicare RAC Denials, Managed Care Denials, Medicaid Denials and oversight of hospital specific managed care contract requirements. Works to appropriately maximize revenue for every patient bed in collaboration with clinical and financial teams. Interfaces extensively with insurance companies to ensure certification and payment for episodes of care. Ensures completion of all Notice of Admissions and Pre-certification for procedures.

Qualifications & Education

Bachelor’s degree required. Licensure and/or certification as required. Current and Valid State of New Jersey license required Certification CPUR, CPHQ or CCM preferred. Minimum 5-7 years experience in utilization management, quality improvement or a related field. Magnet recognized national certification preferred, but RN management is expected to have Magnet recognized national certification within two years of hire into position. Experience – Demonstrated managerial skills as required for the position. Demonstrated managerial skills as required for the position. Magnet recognized national certification preferred, but RN management is expected to have Magnet recognized national certification within two years of hire into position.

Area of Talent: Management

Organization: The Valley Hospital

Department: VH CARE COORDINATION

Shift: Day

Full Time

Schedule: 8:00 am – 4:30 pm

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