Utilization Review Nurse- 40hr
2 weeks ago
Utilization Review Nurse 20hr at Connecticut Childrens Center for Care Coordination
About UsConnecticut Childrens is a dedicated childrens health system serving over 30 pediatric specialties across Connecticut and in two other states. Our mission is to transform childrens health and well?being through personalized care, innovative research, and community partnerships.
Job DescriptionUtilization Management Nurse supports the hospitals UM program by conducting medical necessity reviews, managing diverse workload in a fast?paced regulatory environment, and collaborating with leaders across the organization. The RN performs chart reviews, screen for appropriateness of level of care, perform concurrent and retrospective reviews, and report key metrics. The RN also provides education to physicians regarding documentation and engages case management and care team colleagues in problem?solving.
Responsibilities- Conduct chart review to identify quality, timeliness, and appropriateness of patient care.
- Perform hospitalization reviews for Medicaid beneficiaries and other insurers based on guidelines.
- Gather clinical information and conduct continued stay utilization review activities with payers.
- Escalate cases as appropriate for secondary review.
- Perform concurrent and retrospective clinical reviews utilizing appropriate guidelines.
- Adhere to CMS guidelines for utilization reviews and referrals for secondary review.
- Collaborate with case management and care team colleagues to reduce length of stay and resource consumption.
- Represent Utilization Management at committees as needed.
- Provide consultation and education to physicians regarding documentation necessary to support ordered level of care.
- Keep current on all regulatory changes affecting acute care services.
- Use coverage determinations to advise physicians.
- Promote evidence?based protocols and order sets.
- Apply industry accepted level of care criteria and advocate for appropriate use of hospital resources.
- Demonstrate self?directed, organized, diplomatic, and team?oriented skills.
- Facilitate effective communication within the healthcare team to promote continuity of care.
- Skill in computer systems including Microsoft Office and EPIC.
- Prioritize and manage multiple tasks.
- Collaborate with team to coordinate right care in the right setting at the right time for CT Childrens patients.
- Identify gaps in care/resources and address issues that negatively impact access to care, services, and resources.
- Act as a change agent, advocate, and resource person for family and healthcare team to resolve performance improvement issues.
- Commit to ONE TEAM Culture.
Education and Experience Required
- Bachelor of Science in Nursing (BSN).
- 3 years of nursing in a healthcare setting.
- Pediatric nursing experience.
- Previous experience in Utilization Review.
- Previous experience in Case Management or Discharge planning.
- Connecticut Nursing License.
- Case Management Certification.
- Interpret medical care criteria and apply evidence?based protocols.
- Coordinate complex patient populations and use community resources.
- Proficient in Microsoft Office and EPIC.
- Excellent written and verbal communication skills.
- Self?directed, organized, and able to manage multiple tasks in a fast?moving environment.
Seniority Level
Mid?Senior level
Employment TypeFull?time
Job FunctionHealth Care Provider
ContactApply by visiting Connecticut Childrens Center for Care Coordination site.
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