Utilization Review Nurse

apartment CareWell Health Medical Center location_onEast Orange, NJ, US

Job Summary

The Utilization Review Nurse is responsible for ensuring that patients receive appropriate, cost-effective care by reviewing medical records, treatment plans, and healthcare services. The role involves collaborating with healthcare providers and an interdisciplinary team to optimize resource utilization and improve patient outcomes. The Utilization Review Nurse ensures parties follow The Joint Commission standards, authorizations and medical necessity, fiscal stability through denials review, and monitors Length of Stay efforts of the Hospital.

Essential Functions

Conduct detailed reviews of patient medical records to ensure treatments and services meet established guidelines and criteria.
Assess the appropriateness of proposed treatment plans and recommend modifications to enhance patient care and resource efficiency.
Assists with the denials process with focus on clinical reviews, peer-to peer reviews, payer communications, tracking and other duties related to denials and denials prevention.
Complete all inpatient admission and observation reviews for all inpatient units, with priority to observation cases and denied inpatient admissions with commercial insurance.
Provide education and support to healthcare staff regarding utilization review processes, best practices, and regulatory requirements.
Participate in quality improvement initiatives, contributing to the development and implementation of utilization review policies and procedures.
Maintain comprehensive and accurate documentation of all reviews, authorizations, and communications with healthcare providers and insurance companies.
Assists the Director of Quality with developing specific departmental goals, standards, and objectives which directly support the strategic plan and vision of the organization as requested
Other duties as assigned.

Functional/Technical Skills Requirements

Comprehensive understanding of operational health care delivery systems and the current health care landscape. Skills and experience with developing competitive business strategies for health care and operational aspects of health care technology deployment. Familiarity and comfort with technology-based operational improvement.
Communications: Excellent written and verbal communications skills. Ability to take abstract, complex and/or technical information and effectively convey the message for a variety of audiences at their level of comprehension.
Functional Oversight: Issue identification, gap analysis, ability to prioritize business needs and execute solutions.
Technology: Proficient in use of health care technology. Skilled in technology-based operational improvement: auditing, data aggregation, monitoring.

Minimum Education/Certification

Knowledge of New Jersey and national quality management and regulatory standards, including reporting.

Bachelor's degree in Nursing, Healthcare Administration, or a related field

Current RN license or equivalent clinical certification

Preferred Education/Certification

Certification in CPUR, HCQM, or CPHQ

Master's degree in healthcare

Minimum Work Experience

Required 1 year of experience in quality improvement and/or utilization review in an acute care setting.

Minimum of 2 years of related experience in utilization review, case management, or related field.

Share this job

Related Jobs

MDS

Full-time

MDS Coordinator

apartment Autumn Lake Healthcare at Old Bridge location_onOld Bridge, NJ

Join our wonderful team as a MDS Coordinator today! Autumn Lake Healthcare at Old Bridge is an exceptional team-oriented company hiring for MDS Coordinator! We provide our staff with the resources, tools, and training needed to succeed and grow in their current and desired future positions. We pride ourselves on our caring and compassionate management team who are there to fully support our staff and residents. Benefits for MDS Coordinator: Referral Bonuses! Competitive Rates! Wonderful Environment! Great Benefit package! Qualifications & Experience Requirements for MDS Coordinator: Previous Experience as a MDS Coordinator preferred Must possess, as a minimum, a Nursing Degree from an accredited college or university Must have, as a minimum, 1 year(s) of experience in a hospital, long-term care facility, or other related health care facility INDOP

Full-time

Registered Nurse

apartment Community Options, Inc. location_onNY

Description Community Options, Inc. is a national non-profit agency providing services to individuals with disabilities in 12 states. We are now hiring a Full Time Registered Nurse in Queens, NY . The Registered Nurse delivers care to individuals with disabilities in a community setting utilizing the nursing process of assessment, planning, intervention, implementation, and evaluation. This person will interact with individuals, significant others, and health team members while maintaining the standards of professional nursing. This position will support our Queens and Manhattan regions. Starting pay is $100,000/per year Responsibilities Provide treatment and health care procedures ordered by a physician and required by the standards of professional practice or law Ensure individuals attend medical appointments per their Individual Support Plan (ISP) Advise supervisor of all concerns and issues related to the provision of nursing services Create and distribute medical/health reports detailing general health, health care goals, and physician recommendations Conduct programmatic trainings including medication administration and delegation Develop and update Individual Support Plans (ISP)/Person Centered Plans (PCP) with an interdisciplinary team to include any concerns, observations, and behavioral developments Train employees on the medical needs of assigned individuals Monitor health and medical conditions of individuals and refer for medical services as needed Monitor the use of medications through medication administration logs Additional tasks and responsibilities may be assigned Employee must cooperate with the license and department staff in any inspection, inquiry, or investigation Minimum Requirements Bachelor’s degree or equivalent experience in nursing field Minimum of one year of experience providing nursing services to individuals with disabilities Valid R.N. license Valid driver’s license with a satisfactory driving record Understanding and commitment to community-based support for persons with disabilities Excellent verbal and written communication skills Employment is contingent upon successful completion of checks of criminal background, central registry, child abuse registry, and drug testing Why Community Options? Competitive Insurance Options (Medical, Dental, Vision) (Day 1) Paid Holidays—Including a Birthday Holiday! Generous Paid Time Off (PTO). Employee Incentive & Discount Programs. 403b Retirement Plan. Exceptional Career Growth Opportunities. Great coworkers/team that support you! University partnerships that include tuition reduction Please Visit Our Website to Complete an Online Application! Careers.comop.org Community Options is an Equal Opportunity Employer M/F/D/V #IND-QU

Full-time

RN (Triage & Support)

apartment Axia Women's Health location_onEast Brunswick, NJ

$29 - $37 / HOUR

At Axia Women’s Health , recognized as a Great Place to Work for a 4th year in a row, our vision is to lead the way in improving women's health. At the core of achieving this is a caring, connected, and progressive community of over 400 providers across nearly 200 women's health centers in New Jersey, Pennsylvania, Indiana, Ohio, and Kentucky. The rapidly growing network spans OB/GYN physicians, breast health centers, high-risk pregnancy centers, two laboratories, urogynecology care, and fertility centers. Together, Axia Women's Health puts women first by delivering the personalized care needed for women to lead healthier, happier lives. We have an opening for a Registered Nurse to perform triage and support. Location: East Brunswick, NJ Hours: Full time hours Monday-Friday 9-5:30 with Full Benefits. Essential Functions: Responds to patient inquiries via phone and electronic messaging, providing clinical triage and guidance in accordance with established nursing protocols. Accurately documents symptoms, nursing assessments, advice given, and patient responses in the EMR. Communicates results of laboratory and imaging tests as directed by the provider, including patient education and follow-up instructions. Collaborates with physicians and advanced practice providers to determine appropriate clinical actions based on patient concerns and symptoms. Processes medication refill requests in accordance with provider direction and practice protocols. Supports care coordination by managing patient follow-up needs, referral communications, and scheduling logistics. Performs nursing tasks such as vital signs, injections, and phlebotomy as needed to support patient care delivery. Maintains awareness of and adherence to clinical policies, procedures, and protocols to promote consistent and safe patient care. Participates in quality improvement initiatives and contributes to a positive team-based care environment. Skills: Strong clinical assessment and decision-making skills Proficiency in documenting within an electronic medical record (EMR) system Excellent communication and interpersonal skills Ability to manage competing priorities and function in a fast-paced environment Competency in phlebotomy and standard nursing procedures Education & Experience: Graduate of an accredited nursing program required Must hold current and unrestricted Registered Nursing license applicable to care center's location(s) Minimum of 1 year experience in an outpatient clinical setting preferred Phlebotomy experience required CPR certification required Experience with eClinicalWorks EMR strongly preferred Familiarity with OB/GYN or women’s health patient populations beneficial Understanding of lab order sets and CPT coding a plus Willingness to support at satellite locations if needed Pay or shift range: $29 to $37 The estimated range is the budgeted amount for this position. Final offers are based on various factors, including skill set, experience, location, qualifications and other job-related reasons. Part Time Benefits Summary Immediate 401(k) contribution option with employer match after one year. Generous PTO offering with additional time off for volunteering At Axia Women’s Health, we’re passionate about creating a community where our colleagues and patients feel empowered to be their full, authentic selves. We welcome all individuals – without regards to gender, race, ethnicity, ability, or sexual orientation – and proudly celebrate our individual experiences and differences. In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification form upon hire. Applicants must be currently authorized to work in the United States on a full-time basis.

Per Diem

Registered Nurse (RN)

apartment IntelyCare location_onOld Bridge, NJ

$44 - $66 / HOUR

Earn up to $66 an hour as a Registered Nurse (RN) in and around Old Bridge, NJ, as a W2 employee with the power to design your own work schedule. As a nurse-founded company, we don't treat flexibility as just one of our many perks — to us, it's a must. On our team, you'll always be fully empowered (with workplace benefits and support) as you decide which shifts at our partner facilities work best for you. We know how committed you are to your work, so why not commit to your personal goals too? Maybe it's a fitness-related initiative that's easier to maintain when you can take the rest days you need. Stop feeling like the outside time you crave on the trailhead of Cheesequake State Park needs to come with a side of work-related guilt. Whether it's amongst the trees or on the waterfront of Seidler Beach, the experiences that matter are finally yours to enjoy. Ready to recharge your love of the job with the self-managed work-life balance that we offer? See more of what we offer below and consider joining our dedicated team today. Benefits RN hourly rate between $44 and $66 Get paid rates that are up to 25% higher on average, with weekly and daily pay options Opportunities for overtime as well as boosted rates for holidays Quickly find shifts in all states where you're authorized to practice Set your own schedule by selecting only your preferred shifts at any of our partner facilities Choose from weekday/weekend shifts, day/evening/overnight shifts, and more 401k retirement plan Upskilling opportunities with a dedicated team of quality assurance nursing professionals Eligibility for medical, dental, and vision insurance for you and qualifying family members Employer tax withholding each pay period Employer coverage for workers' comp and malpractice insurance Undergraduate and graduate tuition discounts at Excelsior University (up to 34%) Manage your shifts and access workplace perks like free continuing education courses through an all-in-one app At IntelyCare, you get a job and a schedule that you manage, but also a supportive community that has your back. Here's how some of our own nursing professionals have described the experience: "I love working with IntelyCare because of all the perks and benefits it provides. There are a variety of facilities to choose from in the app. At first I was going to multiple facilities until I found my two favorites, where I now work full time. I love it!" "I love how flexible this job is! I am a busy mom, so accepting last minute ‘hero’ shifts typically works out better than scheduling shifts in advance. I appreciate the pay and the additional bonuses." "IntelyCare has exceptionally high rates, a variety of facilities, and an easy and fun app to use. The staff here are all very personable and knowledgeable as well, which makes things so much easier. This is truly a 5-star agency." "I love IntelyCare because everything has been easy from the application process until now. There has never been a question unanswered, and everyone is always happy to help with whatever I needed. They always advocate on our behalf. I am so grateful to be an IntelyPro." Job Responsibilities Providing high-quality RN care in post-acute facilities Reviewing various care options with the medical team, residents, and their family members Coordinating with clinical teams to develop individualized care plans Being accountable to follow and adhere to resident care plans Administering appropriate medications and treatments to residents Drawing fluids as needed for labs and testing Using and monitoring medical equipment and devices to ensure effectiveness Training and supervising nursing professionals and other care staff consistent with scope of practice guidelines Promoting staff compliance with all applicable laws, regulations, facility policies, and nursing standards of care Documenting all relevant data to include vital signs, nursing interventions and responses, and resident histories Assisting staff members with incident investigations and the development of care best practices Qualifications and Skills Current New Jersey state license to practice as a Registered Nurse (RN) 6 months of experience (in an RN or related role) Completion of an approved nursing program High level of organizational skills Demonstrated ability to effectively communicate across medical and nursing teams Ability to lift at least 50 lbs Ready for a Job That Puts Your Needs First? As you search for Registered Nurse (RN) jobs in your area, you don't have to settle for the work-life imbalance that you may be used to. If you're ready for something better, we're ready for you. Take the next step today by applying to the team ranked #1 in quality. COVID-19 Considerations: COVID-19 vaccination requirements vary by state. We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status. Location: Old Bridge, New Jersey 08857

MDS

Full-time

MDS Coordinator

apartment American Medical Associates location_onDobbs Ferry, NY

MDS Coordinator- LTC Located in Dobbs Ferry, NY **Salary: $54 - $57 per hour; Based on experience** Qualifications: Must have current New York RN license Minimum of 5 years’ experience in long-term care Thorough knowledge of MDS and RUGS requirements as well as Federal and New York State requirements Current NYS PRI Assessor number Commitment to maximizing reimbursement MDS Rugs Technical Training Ability to communicate effectively both written and oral, with staff, visitor etc. Strong clinical skills Ability to use computer. Exceptional computation and analysis skills Skilled in Time Management. Microsoft Office Proficiency Responsibilities of the MDS Coordinator: Conduct and coordinate the development and completion of the resident assessment (MDS) Maintain and periodically update written policies and procedures that implement MDS and care plan. Assist the resident in completing the care plan portion of the resident’s discharge plan. Develop and implement procedures with the Director of Nursing Services to inform all assessment team members of the arrival of newly admitted residents. Assist Facility directors and supervisors in scheduling the resident assessment and care plan meetings. Assist in determining appropriate treatment, selecting activities and exercises based on medical and social history of residents. Participate in the development and implementation of resident assessments (MDS) and care plans, including quarterly and annual reviews. #6143