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Utilization Management

Throughout much of our history, NJPR served in various capacities for state and federal utilization review and quality assessment programs. We bring this expertise to our clients including hospitals, attorneys and special investigation units. As a neutral party with over thirty five years of experience, NJPR offers a level of support you can trust. Working within several markets allows us to bring our experience to enhance the delivery of patient care and ensure services are supported by appropriate documentation.

The NJPR review staff has the familiarity, flexibility and ability to function with ease in facilities when increases in admissions, vacation time or illness deplete hospital resources to fulfill time sensitive concurrent and retrospective review requirements. We are able to provide support for short and long term assignments.

NJPR conducts staff training for medical necessity determinations and application of clinical information for day to day operations or to respond to medical necessity denials from payers or auditing agencies. These one-on-one or small group tutorials can enhance your new employee orientation program.

In addition to our experienced utilization review nurses, NJPR has formally trained credentialed Legal Nurse Consultant and credentialed coders who can provide support and assistance with the preparation of medical malpractice, product liability, workers compensation, disability determinations, administrative law and other medical legal issues.

NJPR works closely with attorneys and their physician clients on matters concerning medical necessity denials or rejected claims due to non supporting documentation.

As an approved agency by the New Jersey Board of Medical Examiner, NJPR assists with corrective action plans ranging from chart review and analysis, one-on-one training on documentation requirements and evaluation of templated information in the electronic health record.

NJPR has reviewed hundreds of thousands of physician encounters for evaluation of appropriate coding and medical necessity. Many times, cases brought to us have been denied by payers or have been identified as having aberrant patterns in claim submission and require in depth review of documentation and coding. Our experience in utilization review and evaluation of medical necessity coupled with our coding expertise offers a comprehensive and balanced assessment and determination. Detailed reporting allows our client to develop corrective action. NJPR has served as expert witness in arbitration hearings. Typically our services are on a fee for service, non contingency basis.