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POST DATE 9/1/2016
END DATE 11/23/2016

Meridian Health System, Inc Neptune, NJ

Neptune, NJ
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Mid-Career (2 - 15 years)
Bachelors Degree



Review Activities: Admission review, admission denial, continued stay review, continued stay denial, termination of benefits, communication of information to insurance company, billing certification, concurrent managed care, Denial Appeals, retrospective medical record utilization review. Obtains and evaluates medical records for inpatient admissions to determine if required documentation is present. Obtains appropriate records as required by payer agencies and initiates physician advisors as necessary for unwarranted admissions. Conducts on going review and discusses care changes with attending physicians and others. Performs chart reviews for appropriateness of admission and continued hospital stay applying appropriate clinical criteria. Performs admission review within 24 hours or the first business day. Refers cases not meeting criteria to the physician advisor for determination and action.


RN BSN preferred

Certified Case Manager preferred

Licensed as a registered nurse in the state of New Jersey

Minimum of five years experience in the acute care setting

Previous case management/utlization review experience preferred

Knowledge of DRG payer issues and documentation requirements

Knowledge of federal and state regulations, third party payers/managed care principles

Knowledge of InterQual/Milliman criteria and other guidelines for medical necessity, appropriate level of care and concurrent patient management

Knowledge of health care delivery system, utilization review and case review procedures

Computer skills to include Microsoft Word, Excel and basic data entry

Strong organizational and problem solving skills

Excellent oral, written and interpersonal skills

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.