Director of Utilization Management - Full Time
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Job Description
"- Education/Exp: RN, BSN with 10+ years of clinical experience.
- Expertise: MCG or InterQual Certified; expert in CMS, NJ Medicaid, and commercial payer policies. Certification in use and instruction required. Excel, Copilot, data analysis, and tracking and reporting productivity.
- Systems: Strong proficiency in MCG or like tool and PBO Super User.
- Leadership: Ability to partner across multidisciplinary workgroups (MDs, PAs, Surgeons, IT, and Registration) to drive clean timely compliant daily claims processing.
POSITION SUMMARY
- Compliance Ownership: Serve as the primary owner for sustaining compliance in accordance with CMS.gov guidelines. Lead the Utilization Review Committee and manage partnership with Physician Advisors to ensure clinical and regulatory alignment with PCRM quarterly sessions.
- Regulatory & Policy Alignment: Ensure all UM activities strictly adhere to CMS, NJ Medicaid requirements, and evolve commercial payer policies to prevent technical denials.
- LOC & IPO Management: Coordinate daily Level of Care (LOC) and support Inpatient Only (IPO) workgroup, compliant surgical placement, and revenue protection.
- Performance Monitoring: Actively monitor department dashboards; identify trends and execute corrective action plans when metrics deviate from targets.
- Integrated CDI: Create the foundations and Lead Outpatient CDI in Observation settings and collaborate with Quality, Sepsis, and CDI teams
- Education: Train MD/RN teams and partner with new hire orientation to socialize on Inpatient criteria and appropriate use AI-driven identification tools.
- Payer Alignment & Approvals: Complete initial and continued stay reviews within 24 hours to ensure payer awareness, maximize authorization rates, and reduce retrospective denials.
- Length of Stay (LOS): Maintain average LOS at or below the GMLOS through aggressive barrier removal and timely discharge planning partnered with CM and D/C planning.
RN, CPC, CDIC, CRCS, MCG or InterQual Certified; expert in CMS, NJ Medicaid, and commercial payer policies.
Certification in use and instruction required.
Excel, Copilot, data analysis, and tracking and reporting productivity
Total Rewards at AtlantiCare
At AtlantiCare, we believe in supporting the whole person. Our market-competitive Total Rewards package is designed to promote the physical, emotional, social, and financial well-being of our team members. We offer a comprehensive suite of benefits and resources, including:
Generous Paid Time Off (PTO)
Medical, Prescription Drug, Dental & Vision Insurance
Retirement Planswith employer contributions
Short-Term & Long-Term Disability Coverage
Life & Accidental Death & Dismemberment Insurance
Tuition Reimbursementto support your educational goals
Flexible Spending Accounts (FSAs)for healthcare and dependent care
Wellness Programsto help you thrive
Voluntary Benefits, including Pet Insurance and more
Benefitsofferings may vary based on position and are subject to eligibility requirements.
Join a team that values your well-being and invests in your future.
"Apply Now- Job Identification01-39583
- Job CategoryNursing
- Job ShiftVaries
- Pay Range$86,751 - $151,814 per year
- Holidays RequiredNo
- Weekends RequiredYes
- Hrs Per Week40
Generous Paid Time Off (PTO)Medical, Prescription Drug, Dental & Vision InsuranceRetirement Plans with employer contributionsShort-Term & Long-Term Disability CoverageLife & Accidental Death & Dismemberment InsuranceTuition Reimbursement to support your educational goalsFlexible Spending Accounts (FSAs) for healthcare and dependent careWellness Programs to help you thriveVoluntary Benefits, including Pet Insurance and more
Benefits offerings may vary based on position and are subject to eligibility requirements.
Join a team that values your well-being and invests in your future.
Pay Transparency In order to support the Fair Compensation Strategy by the US Govt., HR Dept., clients are required to adhere to "Pay Transparency Law" in impacted states, which mandate employers to list salary ranges in job advertisements and promotions.
AtlantiCare is an Equal Opportunity Employer
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