Clinical Denials Utilization Review RN Utilization Resource Management Pennington NJ

Capital Health is the region’s leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than
600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates.

The listed pay range or pay rate reflects compensation for a full‑time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part‑time).

$86,964.80 - $

40

Performs Utilization Review function for Capital Health related to third party reimbursement, denials, appeals and clinical audits for inpatient cases. Ensures responsibility for Performance Improvement, and Quality Improvement activities in department. Prepares and submits appeals timely and ensures completion of UR inpatient appeal process.

Education:

Graduation from an accredited School of Registered Nursing.

Experience:

Five years’ experience in nursing. Three years’ experience in case management field including utilization review, discharge planning, outcomes management, assessment, care planning, and/or care coordination. Inpatient denial appeal experience preferred.
Other Credentials:
Registered Nurse - NJ
Knowledge and

Skills:

Knowledge of CMS guidelines, payor specific guidelines, contractual rules, and applicable clinical guidelines. Ability to interpret a variety of instructions furnished in written, oral, diagram or schedule form.
Special Training:
Proficient in Word, Excel, Outlook, and other Utilization review software and patient information EMR software.
Mental, Behavioral and Emotional Abilities:
Usual Work Day: 8 Hours
Reporting Relationships
Does this position formally supervise employees? No

Monitors inpatient utilization process and ensures that process is performed adequately on all inpatients in accordance with applicable standards, regulations and payer contracts.
Actively supports denial and appeal process for the department. Interfaces with Health Information Management (HIM) and billing departments to coordinate clinical components to ensure appropriate reimbursement.
Performs accurately chart and utilization review audits as directed. Supports Capital Health Utilization Committee with analysis of clinical outcomes data.
Prepares for and maintains accurate records of utilization audits by payors and QIO. Maintains current and accurate knowledge of relevant CMS, NJDHSS, DOBI and QIO regulations related to managed care and utilization.
Participates in DNV and other regulatory readiness and preparation activity, as directed.
Develops departmental performance improvement projects.
Oversees denial life cycle process for the department. Enters and updates denials into UR software system.
Reviews and updates denial status from pending and open denials (concurrent reconsideration and peer‑to‑peer review) to sending denials for formal appeals daily.
Prepares and electronically submits for retrospective appeal.
Prepares and submits written appeal to auditing agency.
Monitors, tracks and completes retrospective audit denial appeals process.
Track denial life cycle tracking and monitoring using an excel electronic platform.

Frequent physical demands include:
Sitting, Standing, Keyboard use/repetitive motion
Occasional physical demands include:
Walking, Climbing (e.g., stairs or ladders), Carry objects, Push/Pull, Twisting, Bending, Reaching forward, Reaching overhead, Squat/kneel/crawl, Wrist position deviation, Pinching/fine motor activities
Continuous…