Job Description

Job Description

Hourly Rate: $50.00

About Christian Health:

We have had the privilege of caring for those in need for more than a century. Founded on the belief that everyone has the right to exceptional care, today we continue to provide quality care and services for our many residents, patients, and clients. Caring is not simply what we do, it is who we are.

Why Join Our Team:

Across our four campuses, eleven communities, five service offerings, and hospital, we are ultimately one unified team. Together, we nurture a compassionate, collaborative culture that enables continuous improvement and allows our team members to learn, grow, and shine in their careers. Surround yourself with people who care about making a difference – come join us!

We have an exciting opportunity for a part-time Utilization Review Nurse to work in Ramapo Ridge Behavioral Health (RRBH). The Utilization Review Nurse promotes effective utilization and monitoring of health care resources to achieve desired clinical, financial and resource outcomes. Verifies all insurance coverage eligibility, benefit details, pre certification/authorization requirements and billing/claims instructions. Ensures accurate insurance data is available in the medical record. Works collaboratively with the interdisciplinary treatment team to review all managed care medical record documentation for compliance as required in a timely manner. Ensures that medical record documentation for patients admitted to RRBH meets medical necessity criteria for each level of care. Provides for timely and accurate clinical reviews as required to ensure compliance with managed care organizations. Follows up and assesses any managed care denials for risk/benefit of appeal. Demonstrates an understanding of, and embraces, the mission statement of the Christian Health.

About Ramapo Ridge Behavioral Health (RRBH):

• RRBH is a 58-bed inpatient psychiatric hospital licensed by the State of New Jersey and accredited by The Joint Commission (TJC).
• Our behavioral hospital serves adults from 18 years of age through the senior years. RRBH includes a general adult psychiatric division treating adults of all ages with various mental health diagnosis such as depression, bipolar illness, anxiety, schizophrenia, OCD and others. Our geriatric division is a locked, safe and secure newly renovated wing that specializes in various forms of Dementia, Alzheimer’s and a host of additional mental health diagnosis. While we admit patients who are voluntary and involuntary, we are not licensed to admit patients who require Short Term Care Facility (STCF) beds. Generally, these patients require a more intensive and secure environment for safety.

Competencies:

• Obtains Insurance/MCO precerts and Continued Stay authorizations as required.
• Acts as a liaison between professional staff and insurance/managed care organizations.
• Reviews medical record documentation for medical necessity appropriateness for each level of care.
• Performs all concurrent reviews with required outside agencies for reimbursement authorizations.
• Communicates financial information (benefits available etc.) with Treatment Team members when indicated.
• Maintains and documents medical record reviews as appropriate in UR records.
• Maintains timely and accurate documentation for UR Records on patients/clients.
• Performs Admission/Continued/Extended Stay Reviews as required.
• Demonstrates awareness of legal issues in all aspects of hospital reimbursement regulations and strives to manage situations in a manner that reduces financial risk.
• Monitors due dates for Medicare and Medicaid Physician Certifications and notifies the appropriate physician when due.
• Maintains organized filing systems.
• Assists in the daily Partial Hospital Program Services census management.
• Provides "Documentation Helpers" to professional staff as necessary to ensure that adequate, timely and complete documentation exists to indicate medical necessity for appropriateness of level of care.
• Identifies and communicates appropriate aftercare providers for patients/clients with managed care insurance.
• Collaborates with the Treatment Team to facilitate discharge planning.
• Communicates reimbursement and managed care authorizations to the Finance Department.
• Monitors physician admission History and Physical Assessment completeness/timeliness and reports data to HIMS.
• Is an active member of the hospital Ongoing Record Review Team.
• Participates in activities related to clinical outcome data collection and performance improvement monitoring as appropriate.
• Receptive to learning new computer skills to assist in Utilization Management functions.
• Identifies and communicates with the Director of Contract Services out of network cases requiring rate negotiation.
• Obtains referral/authorizations for support services when indicated.
• Issues Physician Advisor Referrals to the Medical Director when lack of medical necessity documentation is identified by UR staff.

Schedule: 9am-1:30pm, Monday - Friday.

Education: A Graduate of an accredited school of nursing or a nursing degree from an accredited college or university. Must be a Registered Nurse or Licensed Practical Nurse in the state of New Jersey.

Qualifications:

• 3-5 years clinical hospital experience (Behavioral Health experience helpful).
• Utilization review/management/quality experience preferred.
• Interpersonal skills to obtain and interpret information appropriate to patient/client needs and age as required for assessment of appropriate level of care criteria and medical necessity guidelines.
• Computer literacy with Microsoft Windows, Outlook, Word, Excel and Internet/Intranet navigation. Keyboarding skills are essential. (Experience with computer data base systems or nursing informatics helpful).
• Must be a Registered Nurse or Licensed Practical Nurse in the state of New Jersey.

Christian Health offers a wide variety of benefits to full-time employees that includes:

• Discounted health insurance
• Dental Program
• Paid Vacation, Personal days, Holidays and New Jersey Sick leave
• 401k plan for all employees who are 21 years old or older
• Group Life Insurance & Voluntary Life Insurance
• Tuition Reimbursement
• Flexible Benefit plan
• Employee Assistance Program
• Direct Deposit
• Credit Union
• Child Day Care Center on campus
• Gift shop on campus
• Free onsite parking on campus
• Free meals for all employees
• Pay differentials
• Exclusive employee discounts and special offers
• Access to earned wages prior to payday

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