Utilization Review Nurse- 20hr

Connecticut Children's Medical Center • Hartford, CT

82d

About The Position

Connecticut Children's is the only health system in Connecticut that is 100% dedicated to children. Established on a legacy that spans more than 100 years, Connecticut Children's offers personalized medical care in more than 30 pediatric specialties across Connecticut and in two other states. Our transformational growth establishes us as a destination for specialized medicine and enables us to reach more children in locations that are closer to home. Our breakthrough research, superior education and training, innovative community partnerships, and commitment to diversity, equity and inclusion provide a welcoming and inspiring environment for our patients, families and team members. At Connecticut Children's, treating children isn't just our job - it's our passion. As a leading children's health system experiencing steady growth, we're excited to expand our team with exceptional team members who share our vision of transforming children's health and well-being as one team. Connecticut Children's Center for Care Coordination (The Center) is dedicated to the integration of care coordination through the delivery of innovative programs, providing technical assistance, disseminating best practices, and building inclusive partnerships to strengthen families and build stronger communities. The Center utilizes a universal, evidence based, research informed, and policy driven approach to enhanced care coordination that not only meets the interrelated medical, developmental, behavioral, and social needs of children, but enhances the care giving capacity of families.

Requirements

• Bachelor of Science in Nursing (BSN).
• 3 years' nursing in a healthcare setting.
• State of Connecticut Nursing License.

Nice To Haves

• Pediatric nursing experience.
• Previous experience in Utilization Review.
• Previous experience in Case Management or Discharge planning.
• Case Management Certification.

Responsibilities

• Coordinates management of care for a specified patient population; follows patients throughout the continuum of care and ensures optimum utilization of resources, service delivery and compliance with hospital standards.
• Provides ongoing support and expertise through comprehensive assessment, care planning, plan implementation and overall evaluation of individual patient needs.
• Performs chart review of assigned patients to identify quality, timeliness, and appropriateness of patient care.
• Conducts hospitalization reviews for Medicaid beneficiaries, as well as other insurers and self-pay patients, based on appropriate guidelines.
• Gathers clinical information to conduct continued stay utilization review activities with payers pursuant to department policies and procedures and the Utilization Review Plan.
• Escalates cases as appropriate for secondary review.
• Performs concurrent and retrospective clinical reviews utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations, policies, and timelines.
• Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals for secondary review.
• Identifies, develops, and implements strategies to reduce length of stay and resource consumption in conjunction with discharge planning staff.
• Identifies and consistently documents information on any progression of care or patient flow barriers using the designated electronic tool used to track avoidable days/delays.
• Engages hospital case management and care team colleagues in collaborative problem solving regarding appropriate utilization of resources.
• Represents Utilization Management at various committees, as needed.
• Identifies and records episodes of preventable delays or avoidable days due to failure of progression-of-care processes.
• Maintains appropriate documentation in the Utilization software system on each patient to include specific information of all resource utilization activities.
• Provides consultation and education to physicians and other qualified practitioners regarding medical record documentation necessary to support the ordered level of care.
• Conveys benefit data and options, programs and other forms of assistance that may be available to the patient, and negotiates for services as indicated.
• Communicates pertinent reimbursement information to healthcare team while observing patient right to confidentiality.
• Verifies in-network versus out-of-network benefits and communicates data to the patient and healthcare team as indicated.
• Keeps current on all regulatory changes that affect delivery or reimbursement of acute care services.
• Uses knowledge of national and local coverage determinations to appropriately advise physicians.
• Promotes the use of evidence-based protocols and/or order sets to influence high-quality and cost-effective care.
• Facilitates effective communication within the health care team to promote continuity of care.
• Collaborates with other members of The Center team to coordinate the right care, in the right setting, at the right time for CT Children's patients.
• Identifies gaps in care/resources and addresses issues that negatively impact access to care, services, and resources.
• Functions as a change agent, advocate, and resource person for family and healthcare team to identify and resolve performance improvement issues within the system.
• Performs other job-related duties as assigned.

What This Job Offers

• Industry: Hospitals
• Education Level: Bachelor's degree
• Number of Employees: 5,001-10,000 employees