RN Case Manager

Personal, compassionate service is what we're known for at NJM. We seek the best and brightest to help our customers when they need us most. As part of the NJM team, you'll not only enjoy some of the best benefits in the industry, you'll also be joining a company that's committed to professional development, diversity and innovative thinking.

Parsippany, NJ

NJM Insurance Group

<p><strong>Come Grow with Us!</strong></p> <p>&nbsp;</p> <p>For more than a century, our policyholders have trusted us to serve them in their times of need. For just as long, we have supported our employees by providing a competitive compensation package and opportunities for growth. If you are looking to be part of something special and make a difference each day, we invite you to come grow with us. There's never been a better time to join the NJM family.&nbsp;</p> <h3>This isn't just insurance.&nbsp;&nbsp;<strong>It's NJM</strong><strong>.<br /><br /><br /></strong>If you don't see the job you're looking for below, please click <a href="https://chu.tbe.taleo.net/chu02/ats/careers/v2/searchResults?org=NJM3&amp;cws=47" target="_blank" rel="noopener noreferrer">here</a> to create a search agent, or log in to check the status of your previous application.&nbsp;</h3> <h3><em><strong>&nbsp;</strong></em></h3> https://www.njm.com/about/careers

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Full Time

Overview: 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. The official NJM job title is Medical Case Coordinator. <br><br/><br/>
Responsibilities: <ul> <li>Provide Case Management services to a caseload of claimants, which includes: comprehensive assessment, planning, implementation and overall evaluation of individual claimant needs.</li> <li>Collaborate with treatment providers to promote rehabilitation.</li> <li>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.</li> <li>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&rsquo;t meet established guidelines for medical necessity to Medical Director for additional review.</li> <li>Maintain accurate records of all communication and interventions, including documentation in the claim system.</li> <li>Participate and support projects around medical management initiatives.</li> <li>Monitor all utilization reports to ensure compliance and identify trends.</li> <li>Assist with the preparation of reports, as needed.</li> <li>Support company and departmental Quality Assurance/Quality Improvement initiatives.</li> <li>Keep current with regulation changes.</li> </ul>
Requirements: <ul> <li>Registered Nurse (RN) in New Jersey</li> <li>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.</li> <li>Ability to travel within NJ.</li> <li>Knowledge of professional nursing principles, clinical practice guidelines, and clinical interventions.</li> <li>Experience with medical record reviews, medical terminology, appropriate level of health care, treatment modalities and health care delivery systems.</li> <li>Excellent relationship management skills, including the ability to influence and/or mentor others with varying levels of experience.</li> <li>Demonstrated ability to problem-solve and resolve complex, multifaceted, and emotionally-charged situations. Competence in negotiation, quality assurance, case management outcomes, and data analysis.</li> <li>Strong organizational, task prioritization and delegation skills.</li> <li>Experience with Microsoft Office products and database programs, data analysis and data management proficiency.</li> </ul> <br /> Preferred: <ul> <li>Experience in Workers Compensation and/or PIP.</li> <li>BSN from an accredited school of nursing.</li> <li>Experience with Utilization Review/Hospital Concurrent Review (monitoring hospital/rehab stays for medical necessity and intensity of service).</li> <li>Knowledge of MCG/Millman, Official Disability Guidelines (ODG) and/or other evidence-based guidelines databases.</li> </ul>