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).

Pay Range:

Scheduled Weekly Hours:

Position Overview

SUMMARY (Basic Purpose of the Job)
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.

MINIMUM REQUIREMENTS
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

If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager.

ESSENTIAL FUNCTIONS
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 submitted 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.

PHYSICAL DEMANDS AND WORK ENVIRONMENT
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 physical demands include:

Lifting Floor to Waist 15 lbs. Lifting Waist Level and Above 10 lbs.

Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Color Discrimination, Minimal Depth Perception, Minimal Hearing

Anticipated Occupational Exposure Risks Include the following: Bloodborne Pathogens , Chemical , Airborne Communicable Disease

This position is eligible for the following benefits:

• Medical Plan

• Prescription drug coverage & In-House Employee Pharmacy

• Dental Plan

• Vision Plan

• Flexible Spending Account (FSA)

- Healthcare FSA

- Dependent Care FSA

• Retirement Savings and Investment Plan

• Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance

• Supplemental Group Term Life & Accidental Death & Dismemberment Insurance

• Disability Benefits – Long Term Disability (LTD)

• Disability Benefits – Short Term Disability (STD)

• Employee Assistance Program

• Commuter Transit

• Commuter Parking

• Supplemental Life Insurance

- Voluntary Life Spouse

- Voluntary Life Employee

- Voluntary Life Child

• Voluntary Legal Services

• Voluntary Accident, Critical Illness and Hospital Indemnity Insurance

• Voluntary Identity Theft Insurance

• Voluntary Pet Insurance

• Paid Time-Off Program

The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level. 

The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.