Utilization Review Nurse- 40hr
About The Position
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. Utilization Management Nurse: The Utilization Review (UR) Nurse has strong clinical skills and a well-developed knowledge of utilization management, with a focus on medical necessity determinations. The candidate should possess a working knowledge of medical necessity tools such as InterQual® and Milliman Care Guidelines® and be proficient in medical record reviews. This individual supports the overall Utilization Management (UM) program by developing and/or maintaining effective and efficient processes for determining the defensible hospitalization status based on regulatory and reimbursement requirements of various commercial and government payers. This individual is responsible for performing a variety of concurrent and retrospective UM-related functions and ensuring that appropriate data is tracked, evaluated, and reported. This individual maintains current and accurate knowledge regarding commercial and government payers including regulatory requirements. The UR Nurse will function in accordance with facility policies and processes. This individual will support process improvement activities and report key metrics to facility leadership as requested. The UR Nurse effectively and efficiently manages a diverse workload in a fast-paced, rapidly changing regulatory environment. The UR Nurse provides support to the hospital’s UM Committee as needed. He/she collaborates with multiple leaders at various levels throughout the organization. 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.
Requirements
- strong clinical skills
- well-developed knowledge of utilization management, with a focus on medical necessity determinations
- working knowledge of medical necessity tools such as InterQual® and Milliman Care Guidelines®
- proficient in medical record reviews
- knowledge regarding commercial and government payers including regulatory requirements
- effectively and efficiently manages a diverse workload in a fast-paced, rapidly changing regulatory environment
Responsibilities
- performing a variety of concurrent and retrospective UM-related functions and ensuring that appropriate data is tracked, evaluated, and reported
- maintaining current and accurate knowledge regarding commercial and government payers including regulatory requirements
- supporting process improvement activities and report key metrics to facility leadership as requested
- providing support to the hospital’s UM Committee as needed
- collaborating with multiple leaders at various levels throughout the organization
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
Number of Employees
1,001-5,000 employees
