Outcomes Manager – UR

This is a fully remote position, open to applicants in New Jersey.

📋 Description

• Accountable for the application of suitable medical necessity tools to ensure compliance while achieving cost-effective and favorable patient outcomes.

• Serves as a resource for fellow team members, including UR Tech and AA, to bolster the UR and revenue cycle processes.

• Employs payer-specific screening tools as a resource to aid in the determination of service levels and medical necessity.

• Engages with the Physician Advisor to discuss matters related to medical necessity, length of stay, and appropriateness of care.

• Identifies and manages concurrent and retroactive denials through effective communication with attending physicians, case management, multidisciplinary teams, external physician resource groups, and payers.

• Ensures accurate and complete documentation of clinical reviews and denial management within the case management and billing documentation systems.

• Oversees the concurrent denial process by directing referrals to the appropriate resources for concurrent and retrospective appeal activities.

• Prepares and conducts audits utilizing the necessary screening tools and documentation.

• Responsible for achieving job-specific goals, objectives, and dashboards that contribute to the organization's success.

• Participates in organizational improvement initiatives, including patient satisfaction, the Six Sigma committee, departmental and divisional teams, and community activities.

• Comprehends and applies relevant federal and state regulations.

• Identifies and reports compliance issues as necessary.

⛳️ Requirements

• Minimum of 3 years of clinical nursing (RN) experience and 1 year of UR/CM/QM experience, or 3 years of experience as a Clinical Social Worker.

• Fundamental understanding of Medicare, Medicaid, and managed care frameworks.

• Background in discharge planning or home health.

• Outstanding verbal and written communication skills.

• Proficient problem-solving abilities.

• Strong critical thinking capabilities.

• Effective conflict resolution skills.

• Valid licensure as a Registered Nurse from the State of New Jersey.

• Case Management Certification (mandatory within one year of hire, commencing April 1, 2015).

🏝️ Benefits

• Medical/prescription insurance.

• Dental insurance.

• Vision insurance.

• Health and dependent care flexible spending accounts.

• 403(b) retirement plan (401(k) subject to collective bargaining agreement).

• Paid time off.

• Paid sick leave as stipulated by state and local paid sick leave laws.

• Short-term disability.

• Optional long-term disability.

• Colleague and dependent life insurance.

• Supplemental life and AD&D insurance.

• Tuition assistance.

• Employee assistance program offering free counseling sessions.