Atlantic Group is partnering with a large local Insurance client currently seeking a Field RN Case Manager in Parsippany, NJ to assure that claimants receive high quality, cost-effective medical care with positive outcomes. This role will involve approximately 30% travel.
- 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
- 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’t meet established guidelines for medical necessity to Medical Director for additional review
- Provide Case Management services to a caseload of approximately 50-80 claimants, which includes: comprehensive assessment, planning, implementation and overall evaluation of individual claimant needs
- RN diploma required, BSN preferred
- Registered Nurse (RN) in New Jersey
- 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
- Experience with PIP (personally injury protection), Workers Compensation, medical record reviews, medical terminology, appropriate level of health care, treatment modalities and health care delivery systems
- Experience with Microsoft Office products and database programs, data analysis and data management proficiency
- Knowledge of professional nursing principles, clinical practice guidelines, and clinical interventions
- Knowledge of MCG/Millman, Official Disability Guidelines (ODG) and/or other evidence-based guidelines databases
- Competence in negotiation, quality assurance, case management outcomes, and data analysis
- Up to 30% travel required
Note: Qualified candidates will be contacted within 2 business days of application. If an applicant does not meet the above criteria, we will keep your resume on file for future opportunities and may contact you for further discussion.