Our West Trenton Medical Service Administration Department (MSA) is seeking a Medical Case Management Specialist with RN license to assure that claimants receive high quality, cost efficient medical care and positive outcomes. The successful candidate will perform all aspects of utilization management: precertification, concurrent review, retrospective review and case management intervention. NJM Title: Medical Management Coordinator
- Review precertification requests for medical necessity, referring to the Medical Director those that require additional expertise.
- Review clinical information for concurrent reviews, managing the Length of Stay for inpatients as appropriate.
- Use effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions to:
- Promote improved quality of care and/or life
- Promote cost effective medical outcomes
- Prevent hospitalization when possible and appropriate
- Promote decreased lengths of hospital stays when appropriate
- Prevent complications in patients under care when possible
- Provide for continuity of care
- Assure appropriate levels of care are received by claimants
- Provide Case Management services to claimants including: comprehensive assessment, planning, implementation and overall evaluation of individual claimant needs.
- Analyze data, draw actionable conclusions, and prepare monthly management reports
- Assist with preparation of quarterly summary reports and Pharmacy Reports
- Maintain accurate records of all communication and interventions
- Support company and departmental QA /QI initiatives
- Keep current with regulation changes
- Bachelors degree
- 2 years of prior experience with Utilization Review and/or Case Management
- Previous training and demonstrated competence in negotiation, quality assurance, case management outcomes, and data analysis
- Strong clinical nursing background
- Knowledge of professional nursing principles, clinical processes and clinical interventions
- Must be knowledgeable about medical terminology, appropriate level of health care, treatment modalities and health care delivery systems
- Ability to perform medical record reviews, including interpreting, abstracting, aggregating, analyzing and reporting complex clinical data obtained from medical records
- Knowledge of clinical practice guidelines and the appropriateness of clinical interventions
- 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
- Strong organizational, task prioritization and delegation skills
- Computer literacy on Microsoft Office products and data base programs
- Data analysis and management proficiency
Company DetailsThe Company (www.njm.com/careers) is an industry leader among its peers and the largest provider of Personal Auto and Workers' Compensation coverage in the state. The Company's reputation of offering excellent service is directly attributed to the performance of our employees, who we believe are our strongest asset and the key to our continued success.NJM is rated A++ (Superior) by A.M. Best Company. NJM is also one of the top ten privately held companies in the state based on its size, according to a 2010 NJBIZ report.NJM seeks career-minded, self-motivated individuals. Selected candidates are rewarded with competitive salaries, career advancement opportunities, educational and employee programs. Our mission is to operate for the exclusive benefit of policyholders and serve the member companies of the New Jersey Business & Industry Association and their employees, consistent with strong underwriting standards for P&C lines and banking products. Our highly valued employees receive an excellent benefits package. NJM is an equal opportunity employer.