Utilization Review Nurse (40 Hour)
About The Position
The State of Connecticut, Department of Mental Health and Addiction Services (DMHAS) is hiring a Utilization Review Nurse for the Southeastern Mental Health Authority (SMHA) in Norwich, CT. This full-time, 40-hour per week position is on the first shift (8:00 am - 4:30 pm, Monday through Friday) within the Quality Management unit. The role involves assessing and reviewing healthcare delivery systems and medical cost containment activities to ensure cost-effective quality of care in accordance with state and federal regulations. DMHAS aims to promote the health and wellness of individuals with behavioral health needs, while SMHA provides high-quality behavioral health services to adults with mental health and substance use disorders in New London County and surrounding towns. Services are recovery-oriented, trauma-informed, and culturally sensitive.
Requirements
- Three (3) years of experience as a Registered Nurse.
- One (1) year of the General Experience must have been in hospital or institutional nursing, in a medical treatment facility, in rehabilitative or occupational nursing or providing medical review of insurance claims.
- Possess and retain a license as a Registered Nurse in Connecticut OR hold a Multistate or Compact Registered Nurse license.
- Considerable knowledge of principles, practices and current trends in nursing.
- Knowledge of and ability to apply relevant state and federal laws, statutes and regulations.
- Knowledge of standards of practice of medicine and nursing as well as other health care disciplines.
- Knowledge of regulations and standards pertaining to utilization review.
- Knowledge of care and service delivery to injured workers.
- Interpersonal skills.
- Oral and written communication skills.
- Ability to analyze patient profile and progress charts to evaluate proper care and treatment.
Nice To Haves
- Experience with Electronic Medical Records System
- Experience with Utilization Review and Management in a healthcare setting
- Experience conducting quality audits for compliance with regulations
- Experience with State and Federal Behavioral Health standards and regulations, including but not limited to: The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), Department of Public Health (DPH)
- Experience providing quality assurance, specifically, writing reports, creating tables and graphs, analyzing data and performance improvement protocols
Responsibilities
- Performs a variety of duties related to review of various types of health and medical care delivery and reimbursement systems.
- Participates in utilization review and/or quality assurance programs.
- Conducts various types of case reviews for quality and appropriate medical management, cost containment, peer review and rehabilitation.
- Summarizes and analyzes data.
- Prepares statistical reports.
- Implements decisions in program according to revisions in standards.
- Attends professional workshops, seminars and in-service training.
- Maintains up to date knowledge of all changes in relevant discipline.
- Monitors personal injuries and medical costs to evaluate need for services billed for appropriate injuries.
- May monitor agency and third-party administrator files to oversee contractor handling.
- May review medical records of various health care eligibility, resource unit referral and/or compliance with federal funding provisions.
- Performs related duties as required.
Benefits
- Professional growth and development opportunities
- A healthy work/life balance to all employees
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
