NJM Insurance Group currently has an RN Case Manager opportunity to assure that claimants receive high quality, cost-effective medical care with positive outcomes. The successful candidate is results-oriented and will perform all aspects of utilization management: case management intervention, precertification, concurrent review, and retrospective review.

This position will require some travel. The official NJM job title is Medical Management Coordinator/Field Nurse Case Manager.

Job Responsibilities:

• Provide Case Management services to a caseload of approximately 40-50 claimants, which includes: comprehensive assessment, planning, implementation and overall evaluation of individual claimant needs.
• Collaborate with treatment providers to promote rehabilitation.
• Review clinical information and perform utilization management, concurrent and retrospective, utilizing established evidence-based clinical guidelines to evaluate treatment plans and/or manage inpatient length of stay.
• Review precertification/preauthorization requests for medical necessity and ensure that treatment is supported by treatment guidelines, medical policies, and/or medical evidence. Refer cases that don’t meet established guidelines for medical necessity to Medical Director for additional review.
• Maintain accurate records of all communication and interventions, including documentation in the claim system.
• Participate and support projects around medical management initiatives.
• Monitor all utilization reports to ensure compliance and identify trends.
• Assist with preparation of reports, as needed.
• Support company and departmental Quality Assurance/Quality Improvement initiatives.
• Keep current with regulation changes.

Required Qualifications and Experience:

• Registered Nurse (RN) in New Jersey
• 3 + years of experience preferred in: Med-Surg and critical care and clinical nursing, Utilization Management Review/Hospital concurrent reviews, and/or Hospital Bill Auditing for inappropriate charges, denials and uncertified days.
• Knowledge of professional nursing principles, clinical practice guidelines, and clinical interventions.
• Experience with medical record reviews, medical terminology, appropriate level of health care, treatment modalities and health care delivery systems.
• Excellent relationship management skills, including the ability to influence and/or mentor others with varying levels of experience.
• Demonstrated ability to problem-solve and resolve complex, multifaceted, and emotionally-charged situations. Competence in negotiation, quality assurance, case management outcomes, and data analysis.
• Ability to travel within NJ.
• Strong organizational, task prioritization and delegation skills.
• Experience with Microsoft Office products and database programs, data analysis and data management proficiency.

Preferred:

• Experience in Workers Compensation and/or PIP.
• BSN from an accredited school of nursing.
• Experience with Utilization Review/Hospital Concurrent Review (monitoring hospital/rehab stays for medical necessity and intensity of service).
• Knowledge of MCG/Millman, Official Disability Guidelines (ODG) and/or other evidence-based guidelines databases.

Legal Disclaimer: NJM is proud to be an equal opportunity employer. We are committed to attracting, retaining and promoting a diverse and inclusive workforce that is fully representative of the diversity that exists in the communities in which we do business.