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 advance technology. Capital Health is a five-time Magnet-Recognized health system for nursing excellence and is comprised of 2 hospitals. Capital Health Medical Group is made up of more than 250 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 minimum pay 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).
Minimum Pay: $86,964.80
Position Overview Min Salary: $41.81
ESSENTIAL FUNCTIONS - Monitors the inpatient utilization process and ensures that the process is performed adequately on all inpatients in accordance with applicable standards, regulations and payer contracts.
- Manages the denial and appeal process for the department.
- Interfaces with the Health Information Management (HIM) and Patient Finance departments to coordinate clinical components to ensure appropriate reimbursement.
- Performs accurately chart and utilization review audits as directed.
- Supports the Capital Health Utilization Committee with analysis of clinical outcomes data.
- Exercises discretion and judgement to evaluate, develop and implement computer based data systems to support the utilization management and reporting functions. Prepares accurate and timely reports on all data collected as directed that demonstrates the effectiveness of the utilization program.
- 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.
- Coordinates the training of staff in utilization management processes ensuring staff expertise and performance.
- Participates in Joint Commission (TJC) and other regulatory readiness and preparation activity, as directed.
- Develops departmental performance improvement projects.
- Manages the UM physician advisor program at Capital Health.
- Oversees the denial life cycle process for the department. Enters and updates denials into the UR software system.
- Reviews all denial entries daily for accuracy (Admission, Continuous Stay, Dropped Level of Care and Retrospective Audit). Corrections made when applicable.
- Reviews and updates denial status from pending and open denials (concurrent reconsideration and peer-to-peer review) to sending denials for formal appeals daily.
- Extracts denials from the UR software system and prepares them in a excel spreadsheet to be electronically submitted for retrospective appeal.
- Updates appeal status upon notification. Manages, reports and writes retrospective Medicaid Appeal Audit denials.
- Prepares and submits the written appeal to the auditing agency.
- Monitors, tracks, manages and completes the retrospective audit denial appeals process.
- Track denial life cycle tracking and monitoring using an excel electronic platform.
MINIMUM REQUIREMENTS Education: Graduation from an accredited School of Registered Nursing.
Experience:Five years of experience in nursing. Experience in case management field including utilization review, discharge planning, outcomes management, assessment, care planning, and/or care coordination.
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:Word Processing, Spreadsheet software. Ability to use electronic mail, AS 400 system and other Utilization Management software and patient information software.
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
Offers are contingent upon successful completion of our onboarding process and pre-employment physical. Capital Health will require all applicants to have an annual flu vaccine prior to start date, with the exception of individuals with medical and religious exemptions. "Company will never ask candidates for social security numbers or date of birth during application phase. If you are asked for this information online, you may be a target for identity theft."
For benefit eligible roles, in addition to cash compensation, we provide a comprehensive and highly competitive benefits package, with a variety of physical health, retirement and savings, caregiving, emotional wellbeing, transportation, robust PTO plan, overtime to eligible roles, and other benefits, including "elective" benefits employees may select to best fit the needs and personal situations of our diverse workforce.
The pay rate 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.
