Utilization Review Case Manager, Care Coordination, Per Diem, Day

POSITION SUMMARY:

The Utilization Case Manager performs concurrent utilization review to ensure appropriate level-of-care determinations, medical necessity, regulatory compliance, and effective resource utilization. Collaborates with physicians, payers, Physician Advisors, and care coordination staff to support admission status decisions, prevent reimbursement denials, optimize length of stay, and ensure compliance with CMS and payer requirements. Serves as a resource on utilization management, medical necessity criteria, and reimbursement regulations while promoting quality patient outcomes and organizational performance.

EDUCATION:

Bachelor,s degree (BSN) in nursing required.

EXPERIENCE:

Current Registered Nurse (RN) License in the State of New Jersey required. Experience in case management and/or utilization review experience strongly preferred.

SPECIAL SKILLS:

• Demonstrates knowledge of acute care nursing practice, utilization review principles, medical necessity criteria, MCG guidelines, and applicable CMS, Medicare, Medicaid, and commercial payer requirements.Understands healthcare documentation standards, reimbursement processes, and utilization management practices.
• Strong communication and collaboration skills when working with physicians, payers, patients, families, and interdisciplinary teams.
• Uses critical thinking, clinical reasoning, and analytical skills to evaluate medical necessity, interpret clinical documentation, and resolve utilization management concerns.
• Proficient in the use of electronic medical records and case management software.
• Manage multiple priorities in a fast-paced environment while maintaining accuracy and attention to detail.
• Interprets complex clinical and regulatory information, works effectively with diverse stakeholders, and remains professional and composed when addressing challenging situations, changing priorities, and reimbursement-related issues.

Job Location

Shift

Benefits

• Medical/Prescription, Dental & Vision Discount Program (Full Time/Part Time Employees)
• Group Term Life Insurance and AD&D(Full Time Employees)
• Flexible Spending Accounts and Commuter Benefit Plans
• Supplemental Voluntary Benefits ( e.g. Short-term and Long-term Disability, Whole Life Insurance, Legal Support, etc.)
• 6 Paid Holidays, Paid Time Off (varies), Wellness Time Off, Extended Illness
• Retirement Plan
• Tuition Assistance 
• Employee Assistance Program (EAP)
• Valley Health LifeStyles Fitness Center Membership Discount
• Day Care Discounts for Various Daycare Facilities

EEO Statement

Valley Health System does not discriminate on the basis of ancestry, age, atypical hereditary cellular or blood trait, civil union status, color, creed, disability, domestic partnership, gender, gender identity or expression, familial status, genetic information, liability for service in the Armed Forces of the United States, marital status, medical condition or illness, mental or physical handicap, national origin, nationality, perceived disability, pregnancy, race, refusal to submit to genetic testing or make available results of such tests, religion, sex, sexual orientation, veteran’s status or any other protected basis, in accordance with all applicable Federal, State and Local laws. This applies to all areas of employment, including recruitment, hiring, training and development, promotion, transfer, termination, layoff, compensation, benefits, social and recreational programs, and all other conditions and privileges of employment.