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.

This position will require some travel. The official NJM job title is Medical Management Coordinator.

Job Responsibilities:

• Provide Case Management services to a caseload of approximately 40-50 claimants, which includes: comprehensive assessment, planning, implementation and overall evaluation of individual claimant needs.

• Collaborate with treatment providers to promote rehabilitation.

• 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.

• Maintain accurate records of all communication and interventions, including documentation in the claim system.

• Participate and support projects around medical management initiatives.

• Monitor all utilization reports to ensure compliance and identify trends.

• Assist with preparation of reports, as needed.

• Support company and departmental Quality Assurance/Quality Improvement initiatives.

• Keep current with regulation changes.

  Required Qualifications and Experience:

• 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.

• Knowledge of professional nursing principles, clinical practice guidelines, and clinical interventions.

• Experience with medical record reviews, medical terminology, appropriate level of health care, treatment modalities and health care delivery systems.

• Excellent relationship management skills, including the ability to influence and/or mentor others with varying levels of experience.

• Demonstrated ability to problem-solve and resolve complex, multifaceted, and emotionally-charged situations. Competence in negotiation, quality assurance, case management outcomes, and data analysis.

• Ability to travel within NJ.

• Strong organizational, task prioritization and delegation skills.

• Experience with Microsoft Office products and database programs, data analysis and data management proficiency.

  Preferred:

• Experience in Workers Compensation and/or PIP.

• BSN from an accredited school of nursing.

• Experience with Utilization Review/Hospital Concurrent Review (monitoring hospital/rehab stays for medical necessity and intensity of service).

• Knowledge of MCG/Millman, Official Disability Guidelines (ODG) and/or other evidence-based guidelines databases.

  Legal Disclaimer: NJM is proud to be an equal opportunity employer. We are committed to attracting, retaining and promoting a diverse and inclusive workforce that is fully representative of the diversity that exists in the communities in which we do business.

  What Makes NJM Different? The NJM team comprises talented people who do the right thing by our policyholders and each other. You’ll be part of a financially strong and stable company that has flourished on relationships, integrity, and service for more than a century. NJM is a special place where you can propel your career, help others, and make friends—all at the same time.

  NJM is proud to offer our employees continuous learning options, outstanding benefits, access to wellness programs, and opportunities to give back to the communities we are privileged to serve.

  We have been named a Forbes America’s Best-in-State Employer for five consecutive years.

  Come join us! It’s time for you to make a difference on our remarkable team.