RN Hospital-Women's Health Full-Time

2 weeks ago

New Haven CT, United States Yale University Full time

University Job Title
Bargaining Unit
None - Not included in the union (Yale Union Group)
Full time
Clinical & Research
Clinical, University Health
Full-time – 37.5 HRS, generally weekdays 8:30 a.m. – Part-time schedules will be considered. Flexibility to work occasional evenings or weekends as needed to meet project deadlines or manage urgent review. Reporting to the Yale Health Medical Director, this position is responsible for identifying opportunities to optimize the utilization of healthcare resources through the administration of the benefit for members of Yale Health. The Utilization Review RN is responsible for assessing the necessity, appropriateness, and efficiency of healthcare services provided to patients. This role ensures that care is delivered in a cost-effective manner while meeting quality standards, within the Yale Health benefit design. The Utilization Review RN will work closely with healthcare providers, patients, and the insurance benefit to facilitate optimal patient care and resource utilization.
Utilization Review and Management: Conduct thorough reviews of patient cases to assess the necessity and appropriateness of medical services and treatments. Evaluate clinical documentation to ensure compliance with established guidelines, medical necessity criteria, and payer requirements. Review and process authorization requests for medical procedures, diagnostic tests, and hospital admissions. Collaborate and provides consultation to healthcare providers and care management team to gather additional information, clarify treatment plans, and address any discrepancies. Review precertification requests for medical necessity, utilizing MCG medical necessity criteria and clinical evidence assessing the treatments appropriateness, effectiveness, timing, and setting, referring to the Medical Director or designee those that require additional expertise. Manages process of request for authorizations (inpatient/outpatient, DME and ancillary services), from member or provider and communicates in a timely manner when the decision has been made. Provides advice and counsel to referral and claims staff for authorization. Notify Billing when there is a possible coordination of benefits issue due to other insurance or automobile accident. Assist Claims with management of Dialysis & Hospice patients. Work with referral team on out of area approvals and second opinions, surgeries, transferring Inpatient patients from out of area to in-network and transition care issues to Care Management as appropriate. Coordinate and collaborate with YNHH and YH care managers for discharge planning recommendations as appropriate.
Quality and Compliance: Ensure adherence to regulatory requirements, clinical guidelines, and payer policies.
Document review outcomes, recommendations, and decisions in the electronic health record (EHR) or utilization management system.
Patient and Provider Interaction: Communicate with healthcare providers regarding authorization approvals, denials, and alternative treatment options. Provide education to patients and providers on utilization review processes, insurance benefits, and care guidelines. Address and resolve any issues or concerns related to care authorization and coverage.
Data Management and Reporting: Analyze utilization trends and generate reports to support decision-making and quality improvement initiatives. Contribute to the development and implementation of policies and procedures related to utilization review.
Work collaboratively with interdisciplinary teams, including physicians, case managers, and social workers, to coordinate patient care and optimize resource utilization. Participate in meetings, case conferences, and quality improvement projects as needed.
Identifies and evaluates nursing services problems and develops and implements appropriate programs and services, including assessing staffing needs and arranging coverage as needed. Develops, implements, and manages nursing care plans in collaboration with physicians. Instructs patients and families in proper treatment and advises patients on health maintenance and disease prevention. Provides leadership, guidance, direction to clinical staff, and collaborates with nursing at all levels. Determines standards for quality assurance and infection control procedures; trains staff in universal and isolation precautions in the area of infection control. Evaluates the quality and effectiveness of nursing practice and nursing services. Records patients’ medical histories and symptoms, performs diagnostic tests and analyzes results, operates medical machinery, administers treatment and medications, and coordinates with patient follow-up and rehabilitation; Bachelor’s Degree in Nursing and two years’ experience or an equivalent combination of education and experience.
Capable of detailed understanding of the healthcare benefits package, identifying cases and situations in which clarification and timely decision making are needed. Experience in a healthcare setting with knowledge of insurance policies, clinical guidelines, and regulatory requirements.
Self-directed with the ability to work independently and consistently utilize a high level of initiative in order to manage work. Proficiency with electronic health records (EHR) and utilization management software. Ability to analyze data and generate reports.
Excellent relationship management skills and able to communicate effectively to all levels of the organization. Superior time management skills.
Master’s Degree in Nursing or Healthcare Administration.
Health Screening
All candidates for employment will be subject to pre-employment background screening for this position, which may include motor vehicle, DOT certification, drug testing and credit checks based on the position description and job requirements. For additional information on the background check requirements and process visit "Learn about background checks" under the Applicant Support Resources section of Careers on the Its Your Yale website.
COVID-19 Vaccine Requirement
The University maintains policies pertaining to COVID-19. All faculty, staff, students, and trainees are required to comply with these policies, which may be found here:
University policy is committed to affirmative action under law in employment of women, minority group members, individuals with disabilities, and protected veterans. Additionally, in accordance with Yale’s Policy Against Discrimination and Harassment, and as delineated by federal and Connecticut law, Yale does not discriminate in admissions, educational programs, or employment against any individual on account of that individual’s sex, sexual orientation, gender identity or expression, race, color, national or ethnic origin, religion, age, disability, status as a special disabled veteran, veteran of the Vietnam era or other covered veteran.
Inquiries concerning Yale’s Policy Against Discrimination and Harassment may be referred to the Office of Institutional Equity and Accessibility (OIEA).

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