Outcomes Manager - UR; Per Diem

Job Summary

Responsible for applying appropriate medical necessity tools to maintain compliance and achieve cost‑effective, patient‑centered outcomes. Acts as a resource to other team members, including UR Tech and AA, to support utilization review and revenue cycle processes.

• Utilization Management
  • Utilize payer‑specific screening tools to determine level of service and medical necessity.
  • Consult with Physician Advisor about medical necessity, length of stay, and appropriateness of care.
  • Identify and manage concurrent and retroactive denials through communication with physicians, case management, multidisciplinary teams, external physician resource groups, and payers.
• Documentation – Provide accurate and complete clinical review and denial management documentation in the case management and billing systems.
• Denial Management
  • Manage concurrent denial processes, referring to appropriate resources for concurrent and retrospective appeal activities.
  • Prepare and facilitate audits using appropriate screening tools and documentation.
• Metrics – Accountable to job‑specific goals, objectives, and dashboards; participate in improvement activities such as patient satisfaction, Six Sigma committee, and community initiatives.
• Compliance – Understand and apply applicable federal and state requirements; identify and report compliance issues as needed.

• Required Experience
  :
  Graduate of an accredited School of Nursing; RN licensure in New Jersey.
• Preferred Experience
  :
  • 3 years clinical nursing (RN) experience and 1 year utilization review / case management / quality management experience,
    ** or**
  • 3 years experience as a Clinical Social Worker.
• Basic understanding of Medicare, Medicaid, and managed care.
• Discharge planning or home health background.
• Excellent verbal and written communication skills, problem solving, critical thinking, and conflict resolution.
• Case Management Certification required within one year of hire (beginning April1,2015).

• Graduate of an accredited School of Nursing.
• New Jersey Registered Nurse license.

Hourly Rate: $38.33 – $59.58 (dependent on experience and internal equity).

• Medical, prescription, dental, and vision insurance.
• Health and dependent care flexible spending accounts.
• 403(b) retirement plan (401(k) subject to collective bargaining).
• Paid time off, paid sick leave per state and local laws, short‑term and optional long‑term disability.
• Life and AD&D insurance, supplemental life and AD&D.
• Tuition assistance and employee assistance program with free counseling sessions.