Sr. Inpatient Utilization Management Nurse

Community Health Network of Connecticut, Inc.•Wallingford, CT

About The Position

Community Health Network of Connecticut, Inc. (CHNCT) is currently seeking a Sr. Inpatient Utilization Management Nurse. This role involves conducting clinical reviews for members receiving care in an inpatient setting. It requires the ability to efficiently filter through large amounts of clinical data, to obtain pertinent information based on condition and presentation, applying clinical guidelines to facilitate appropriate decision making without compromising accuracy. The nurse reviews the appropriateness and medical necessity of admissions utilizing InterQual criteria and makes first level approval determinations, appropriately referring cases to the Medical Director for second level review when the case does not meet InterQual criteria. CHNCT is dedicated to having a workplace where everyone feels valued, respected, and empowered to succeed. They embrace a wide range of perspectives and backgrounds, ensuring fair treatment and opportunities for all employees, and value their team’s rich array of experiences and viewpoints, which contribute to an innovative and collaborative environment. They are also committed to providing an inclusive and accessible interview process, offering reasonable accommodations for interviews due to a disability.

Requirements

Two to four years post-secondary schooling
Bachelor's degree preferred
Nursing major
Three to five years' related experience with at least three years of clinical experience
Strong verbal and written communication skills
Excellent organizational skills, ability to manage multiple priorities concurrently
Strong computer and keyboard skills
Ability to exercise independent and sound judgment in decision making
Team player
Connecticut RN license must be current and unrestricted
Active Registered Nurse License

Nice To Haves

Managed care experience preferred
Experience with InterQual criteria preferred
Knowledge of Medicaid preferred

Responsibilities

Perform Utilization Review of admissions and/or continuing inpatient stay by utilizing standardized clinical criteria as well as the DSS contractual definition of Medical Necessity.
Discuss clinical reviews with Medical Reviewers as needed.
Presents summarized information to medical reviewers when second level review is necessary.
Makes referrals to intensive case management and the behavioral health ASO when appropriate.
Identifies and refers quality of care issues as part of admission and continued stay reviews.
Acts as preceptor to new staff.
May be asked to support other areas of the UM department including performing first level medical necessity reviews for elective inpatient admissions and outpatient services.
Performs other duties as assigned.
Conducts clinical review for members receiving care in an inpatient setting.
Reviews the appropriateness and medical necessity of admissions utilizing InterQual criteria.
Makes first level approval determinations and appropriately refers cases to Medical Director for second level review when case does not meet InterQual criteria.