Utilizes Payer specific screening tools as a resource to assist in the determination process regarding level of service and medical necessity.
Performs utilization review in accordance with all state mandated regulations.
Consults with Physician Advisor to discuss medical necessity, length of stay, and
appropriateness of care issues.
Identify and manage concurrent and retroactive denials through communication with
attending physicians, case management, multidisciplinary team, external physician resource
group and payers.
Completes documentation of review and denial processes in the EPIC Case Management
Responds to requests from the payer for all required information and treatment plans.
Reviews and validates physician’s orders, reports progress and unusual occurrences on
patients to the payer.
Scheduled Days / Hours: as needed weekday and weekend
Bachelor’s degree in Nursing preferred
3-5 years of recent clinical experience, preferably in area of population specialty.
Experience in utilization management or review preferred.
Knowledge and understanding of disease protocols and clinical pathways for commercial and government payors. Familiarity with Interqual and Millimen guidelines and regulatory mandates preferred.
Strong communication (written and verbal) and critical thinking skills required. Professional and effective presentation skills required.
Required License/Certifications/ Registration:
Current NJ-RN License required.
Department Name: Care Management
External Company Name: Cooper University Hospital
External Company URL: cooperhealth.org
Street: 3 Executive Campus