At Virtua Health, we exist for one reason – to better serve you. That means being here for you in all the moments that matter, striving each day to connect you to the care you need. Whether that's wellness and prevention, experienced specialists, life-changing care, or something in-between – we are your partner in health devoted to building a healthier community. 
 
If you live or work in South Jersey, exceptional care is all around. Our medical and surgical experts are among the best in the country. We assembled more than 14,000 colleagues, including over 2,850 skilled and compassionate doctors, physician assistants, and nurse practitioners equipped with the latest technologies, treatments, and techniques to provide exceptional care close to home. A Magnet-recognized health system ranked by U.S. News and World Report, we've received multiple awards for quality, safety, and outstanding work environment.

In addition to five hospitals, seven emergency departments, seven urgent care centers, and more than 280 other locations, we're committed to the well-being of the community. That means bringing life-changing resources and health services directly into our communities through our Eat Well food access program, telehealth, home health, rehabilitation, mobile screenings, paramedic programs, and convenient online scheduling. We're also affiliated with Penn Medicine for cancer and neurosciences, and the Children's Hospital of Philadelphia for pediatrics.

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Summary:

Responsible for application of appropriate medical necessity tools to maintain compliance and achieve cost effective and positive patient outcomes.

Acts as a resource to other team members including UR Tech and AA to support UR and revenue cycle process.

Position Responsibilities:

Utilization Management

• Utilizes Payer specific screening tools as a resource to assist in the determination process regarding level of service and medical necessity.

• 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.

Documentation

• Appropriate and complete documentation of clinical review and denial management in the case management documentation system and in the billing system.

Denial Management

• Manages the concurrent denial process by referring to appropriate resource for concurrent and retrospective appeal activity process.

• Prepares and facilitates audits using appropriate screening tools and documentation.

Metrics

• Accountable to job specific goals, objectives and dashboards which contribute to the success of the organization.

• Participates in organizational improvement activities including patient satisfaction, Six Sigma committee, department and/or divisional teams and community activities.

Compliance

• Understands and applies applicable federal and state requirement.

• Identify and reports compliance issues as appropriate.

Position Qualifications Required / Experience Required:

Preferred: 3 years clinical nursing (RN) experience and 1 year UR/CM/QM experience or 3 years experience as Clinical Social Worker.

Basic understanding of Medicare, Medicaid and managed care.

Discharge planning or home health background.

Excellent verbal and written communication skills, problem solving, critical thinking and conflict resolution.

Required Education:

Graduate of an accredited School of Nursing.

Training/Certifications/Licensure:

Licensure from the State of New Jersey as a Registered Nurse.

Case Management Certification (requirement within one year of hire beginning April 1, 2015).

STAR Standards: Exhibits Virtua’s STAR Standards to create an outstanding patient experience. (Excellent Service, Clinical Quality and Safety, Best People, Caring Culture, Resource Stewardship).

Demonstrates Virtua values in all interactions with our customers, who are patients, families, physicians, co-workers and the community. (Integrity, Respect, Caring, Commitment, Teamwork, Excellence).

For more benefits information click here.