Reporting directly to the Medical Management Supervisor and indirectly to the Medical Management Administrator and Medical Services, the Precert Coordinator supports our Workers Compensation and Auto (PIP/Medpay) lines of business by performing prospective and retrospective Utilization Review of medical services/treatment requested or rendered by medical providers/suppliers to ensure compliance with regulatory guidelines, where appropriate, and to ensure services are clinically supported based upon NJM Medical Policies, standard professional treatment and/or evidence-based guidelines.
Job Responsibilities:
Accurately and effectively evaluate the claim history and current medical records against NJM medical policies and evidence-based guidelines in order to determine whether treatment is clinically appropriate and causally related.
Evaluate requests for precertification/preauthorization/prescreen to determine if treatment is medically necessary, clinically appropriate and causally related based upon a review of the medical records, regulations, NJM Medical, WC, and PIP Policies, standard professional treatment protocols and evidence-based guidelines (ODG and/or MCG).
Conduct retrospective review of medical bills/records to determine if treatment rendered is medically necessary, clinically appropriate, causally related and eligible for reimbursement based upon a review of the medical records, regulations, NJM Medical, WC, and PIP Policies, standard professional treatment protocols and evidence-based guidelines (ODG and/or MCG).
Conduct second level review of PIP Post-Service/Payment Appeals to assess prior determination and new records, including treatment, Independent Medical Examinations, Examinations Under Oath, and legal decisions rendered after the underlying documentation to make recommendations to uphold, modify, or overturn prior decisions.
Conduct Inpatient Care utilization review using NJM and evidence-based clinical guidelines to ensure appropriate level of care and duration.
Communicate regularly with hospitals directly or through liaison to obtain clinical information and updates needed to effectively and accurately perform concurrent review.
Identify medical and community needs and facilitate/assist with post-discharge coordination of care.
Refer requests that meet established criteria for peer review, fail to demonstrate medical necessity, or present high complexity for physician review and determination.
Recognize cases/requests/issues that require consultation with medical, claims, legal staff in order to determine the best approach.
Accurately and concisely document all communications, activities and tasks in the claim systems, as required, in order to support claims management and data collection. Ensure that any guidelines and documentation used to make determination or to refer for peer physician review are referenced.
Understand, apply, and comply with all statutory, regulatory, licensing requirements, and NJM policies/guidelines that affect utilization review and medical management work.
Stay abreast of industry news and trends. Proactively seeks opportunities to increase knowledge on topics that impact property and casualty industry and medical community.
Identify and report medical quality events, as required under the Quality Improvements Program.
Participate and support projects around medical management initiatives.
Identify and/or support company and departmental business process improvements.
Required Skills & Experience:
Actively licensed registered Nurse in New Jersey and Connecticut, Delaware, Maryland, New York or Pennsylvania.
Bachelors of Science and Nursing (BSN) is preferred.
Certified Case Manager (CCM) beneficial
3 years of prior experience in clinical nursing (Med-Surg or Critical Care preferred), Utilization Management Review/Hospital concurrent reviews, and/or Case Management preferred.
Knowledge of professional nursing principles, clinical practice guidelines and appropriate clinical interventions.
Strong grasp of medical terminology, appropriate level of health care, treatment modalities, evidence-based guidelines (MCG and ODG preferred), and health care delivery systems.
Strong decision-making skills.
Strong organizational and task prioritization skills.
Attention to detail.
Ability to navigate technology and multiple systems effortlessly and readily adapt to changes, when needed.
Intermediate Microsoft Office Suite skills (Outlook, Word, Excel, PowerPoint).
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.