Utilization Management Nurse

17 hours ago


New Haven, Connecticut, United States Yale University Full time
Job Summary

We are seeking a highly skilled Utilization Management Nurse to join our team at Yale University. As a key member of our healthcare team, you will be responsible for optimizing the utilization of healthcare resources while ensuring high-quality patient care.

Key Responsibilities
  • 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 with healthcare providers and care management teams 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.
Requirements
  • Bachelor's Degree in Nursing and two years' experience or an equivalent combination of education and experience.
  • Strong clinical assessment and critical thinking skills.
  • Excellent communication and interpersonal skills.
  • Capable of detailed understanding of the healthcare benefits package, identifying cases and situations in which clarification and timely decision making are needed.
Preferred Qualifications
  • Master's Degree in Nursing or Healthcare Administration.
  • Certification in Utilization Review (CPUR or equivalent).
What We Offer

Yale University offers a competitive salary and benefits package, as well as opportunities for professional growth and development.



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