Outcomes Manager – UR

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🏖️ New Jersey – Remote

🏖️ New Jersey – Remote

💵 $38 - $59 / hour

⏱ Part Time

🟡 Mid-level

🟠 Senior

👔 Manager

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Lourdes Health System

WebsiteLinkedInAll Job Openings

10,000+ employees

⚕️ Healthcare Insurance

Healthcare Insurance

Lourdes Health System is a comprehensive healthcare provider, offering a wide range of medical services including heart care, cancer care, neuroscience, orthopedics, OB/GYN, urgent care, surgery, and transplant care. It operates multiple hospitals and urgent care centers across South Jersey, providing telehealth and virtual visit options for convenient access to care. The organization is committed to community health, offering services such as mobile health units, health education, nutrition support, and free cancer screenings. Lourdes Health System aims to build trustful partnerships with patients, providing life-saving procedures and a supportive healthcare experience.

📋 Description

• Responsible for application of appropriate medical necessity tools to maintain compliance and achieve cost effective and positive patient outcomes • Acts as a resource to other team members including UR Tech and AA to support UR and revenue cycle process • Utilizes Payer specific screening tools as a resource to assist in the determination process regarding level of service and medical necessity • Consults with Physician Advisor to discuss medical necessity, length of stay, and appropriateness of care issues • Identify and manage concurrent and retroactive denials through communication with attending physicians, case management, multidisciplinary team, external physician resource group and payers • Appropriate and complete documentation of clinical review and denial management in the case management documentation system and in the billing system • Manages the concurrent denial process by referring to appropriate resource for concurrent and retrospective appeal activity process • Prepares and facilitates audits using appropriate screening tools and documentation • Accountable to job specific goals, objectives and dashboards which contribute to the success of the organization • Participates in organizational improvement activities including patient satisfaction, Six Sigma committee, department and/or divisional teams and community activities • Understands and applies applicable federal and state requirement • Identify and reports compliance issues as appropriate

🎯 Requirements

• 3 years clinical nursing (RN) experience and 1 year UR/CM/QM experience or 3 years experience as Clinical Social Worker • Basic understanding of Medicare, Medicaid and managed care • Discharge planning or home health background • Excellent verbal and written communication skills • Problem solving skills • Critical thinking skills • Conflict resolution skills • Licensure from the State of New Jersey as a Registered Nurse • Case Management Certification (requirement within one year of hire beginning April 1, 2015)

🏖️ Benefits

• medical/prescription insurance • dental insurance • vision insurance • health and dependent care flexible spending accounts • 403(b) retirement plan (401(k) subject to collective bargaining agreement) • paid time off • paid sick leave as provided under state and local paid sick leave laws • short-term disability • optional long-term disability • colleague and dependent life insurance • supplemental life and AD&D insurance • tuition assistance • employee assistance program that includes free counseling sessions