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Job Description
Director of Utilization Management - Full Time Be the First to Apply Job Description "
Education/Exp:
RN, BSN with 10+ years of clinical experience.
Expertise:
MCG or InterQual Certified; expert in CMS, NJ Medicaid , and commercial payer policies. Certification in use and instruction required. Excel, Copilot, data analysis, and tracking and reporting productivity.
Systems:
Strong proficiency in MCG or like tool and PBO Super User.
Leadership:
Ability to partner across multidisciplinary workgroups (MDs, PAs, Surgeons, IT, and Registration) to drive clean timely compliant daily claims processing.
POSITION SUMMARY
Compliance Ownership:
Serve as the primary owner for sustaining compliance in accordance with CMS.gov guidelines. Lead the Utilization Review Committee and manage partnership with Physician Advisors to ensure clinical and regulatory alignment with PCRM quarterly sessions.
Regulatory & Policy Alignment:
Ensure all UM activities strictly adhere to
CMS , NJ
Medicaid requirements, and evolve commercial payer policies to prevent technical denials.
LOC & IPO
Management:
Coordinate daily Level of Care (LOC) and support Inpatient Only (IPO) workgroup, compliant surgical placement, and revenue protection.
Performance Monitoring:
Actively monitor department dashboards; identify trends and execute corrective action plans when metrics deviate from targets.
Integrated CDI:
Create the foundations and Lead Outpatient CDI in Observation settings and collaborate with Quality, Sepsis, and CDI teams
Education:
Train MD/RN teams and partner with new hire orientation to socialize on Inpatient criteria and appropriate use AI-driven identification tools.
Payer Alignment & Approvals:
Complete initial and continued stay reviews within 24 hours to ensure payer awareness, maximize authorization rates, and reduce retrospective denials. Length of Stay (LOS): Maintain average LOS at or below the GMLOS through aggressive barrier removal and timely discharge planning partnered with CM and D/C planning. RN, CPC, CDIC, CRCS, MCG or InterQual Certified; expert in CMS, NJ Medicaid , and commercial payer policies. Certification in use and instruction required. Excel, Copilot, data analysis, and tracking and reporting productivity Total Rewards at AtlantiCare At AtlantiCare, we believe in supporting the whole person. Our market-competitive Total Rewards package is designed to promote the physical, emotional, social, and financial well-being of our team members. We offer a comprehensive suite of benefits and resources, including: Generous Paid Time Off (PTO) Medical, Prescription Drug, Dental & Vision Insurance Retirement Plans with employer contributions Short-Term & Long-Term Disability Coverage Life & Accidental Death & Dismemberment Insurance Tuition Reimbursement to support your educational goals Flexible Spending Accounts (FSAs) for healthcare and dependent care Wellness Programs to help you thrive Voluntary Benefits , including Pet Insurance and more Benefits offerings may vary based on position and are subject to eligibility requirements. Join a team that values your well-being and invests in your future. " Apply Now Job Identification 01-39583 Job Category Nursing Job Shift Varies Pay Range $86,751 - $151,814 per year Holidays Required No Weekends Required Yes Hrs Per Week 40 Total Rewards at AtlantiCare At AtlantiCare, we believe in supporting the whole person. Our market-competitive Total Rewards package is designed to promote the physical, emotional, social, and financial well-being of our team members. We offer a comprehensive suite of benefits and resources, including: Generous Paid Time Off (PTO) Medical, Prescription Drug, Dental & Vision Insurance Retirement Plans with employer contributions Short-Term & Long-Term Disability Coverage Life & Accidental Death & Dismemberment Insurance Tuition Reimbursement to support your educational goals Flexible Spending Accounts (FSAs) for healthcare and dependent care Wellness Programs to help you thrive Voluntary Benefits , including Pet Insurance and more Benefits offerings may vary based on position and are subject to eligibility requirements. Join a team that values your well-being and invests in your future. Pay Transparency In order to support the Fair Compensation Strategy by the US Govt., HR Dept., clients are required to adhere to "Pay Transparency Law" in impacted states, which mandate employers to list salary ranges in job advertisements and promotions. AtlantiCare is an Equal Opportunity Employer Equal employment opportunity, including veterans and individuals with disabilities. PI285238309
