Utilization Review Case Manager, Care Coordination, Per Diem, Day
Valley Health System
Summary
The Utilization Case Manager performs concurrent utilization review to ensure appropriate level-of-care determinations, medical necessity, regulatory compliance, and effective resource utilization. Collaborates with physicians, payers, Physician Advisors, and care coordination staff to support admission status decisions, prevent reimbursement denials, optimize length of stay, and ensure compliance with CMS and payer requirements. Serves as a resource on utilization management, medical necessity criteria, and reimbursement regulations while promoting quality patient outcomes and organizational performance.
Job description
Position Summary
The Utilization Case Manager performs concurrent utilization review to ensure appropriate level-of-care determinations, medical necessity, regulatory compliance, and effective resource utilization. Collaborates with physicians, payers, Physician Advisors, and care coordination staff to support admission status decisions, prevent reimbursement denials, optimize length of stay, and ensure compliance with CMS and payer requirements. Serves as a resource on utilization management, medical necessity criteria, and reimbursement regulations while promoting quality patient outcomes and organizational performance.
Special Skills
- Demonstrates knowledge of acute care nursing practice, utilization review principles, medical necessity criteria, MCG guidelines, and applicable CMS, Medicare, Medicaid, and commercial payer requirements. Understands healthcare documentation standards, reimbursement processes, and utilization management practices.
- Strong communication and collaboration skills when working with physicians, payers, patients, families, and interdisciplinary teams.
- Uses critical thinking, clinical reasoning, and analytical skills to evaluate medical necessity, interpret clinical documentation, and resolve utilization management concerns.
- Proficient in the use of electronic medical records and case management software.
- Manage multiple priorities in a fast-paced environment while maintaining accuracy and attention to detail.
- Interprets complex clinical and regulatory information, works effectively with diverse stakeholders, and remains professional and composed when addressing challenging situations, changing priorities, and reimbursement-related issues.
Requirements
- Bachelor's degree (BSN) in nursing required
- Current Registered Nurse (RN) License in the State of New Jersey required
- Experience in case management and/or utilization review strongly preferred
- Knowledge of acute care nursing practice and utilization review principles
- Knowledge of medical necessity criteria and MCG guidelines
- Knowledge of CMS, Medicare, Medicaid, and commercial payer requirements
- Understanding of healthcare documentation standards and reimbursement processes
- Strong communication and collaboration skills
- Critical thinking, clinical reasoning, and analytical skills
- Proficiency with electronic medical records and case management software
- Ability to manage multiple priorities in a fast-paced environment
Benefits
- Medical, Dental & Vision
- Group Term Life & AD&D
- Flexible Spending Accounts
- Commuter Benefit Plans
- Short & Long-Term Disability
- Whole Life Insurance
- Legal Support
- 6 Paid Holidays
- Paid Time Off
- Wellness Time Off
- Retirement Plan
- Tuition Assistance
- Employee Assistance Program
- Fitness Center Discount
- Day Care Discounts
Company overview
The Valley Health System is an integrated healthcare network serving Las Vegas and Southern Nevada, operating as a subsidiary of Universal Health Services, Inc. (UHS). Established in 1979, the system has grown to become the largest provider of healthcare services in Southern Nevada, serving over two million residents across the region. The network comprises six acute care hospitals, two specialty hospitals, seven freestanding emergency departments, and numerous outpatient facilities and physician practices. Key hospitals include Centennial Hills Hospital Medical Center, Henderson Hospital, Spring Valley Hospital Medical Center, Summerlin Hospital Medical Center, Valley Hospital Medical Center, and West Henderson Hospital. The system offers comprehensive medical services including emergency care, cardiovascular services, neurosciences, maternity and women's health, orthopedics, oncology, behavioral health, and specialized programs in stroke and heart attack care. All Valley Health System hospitals are accredited by The Joint Commission and consistently earn national recognition for quality care, with certifications from the American Heart Association and American Stroke Association. The organization employs over 9,000 healthcare professionals dedicated to providing patient-centered care while also serving as a teaching institution with graduate medical education programs and clinical training opportunities for future healthcare providers.