Utilization Review Nurse (40 Hour)

State of Connecticut•Hartford, CT

3d•Onsite

About The Position

The State of Connecticut Department of Mental Health and Addiction Services is hiring a Utilization Review Nurse for the inpatient unit at Capitol Region Mental Health Center in Hartford. This full-time position is scheduled Monday through Friday, 8:00 AM to 4:30 PM. The role involves assessing and reviewing health care delivery and reimbursement systems to support cost-effective, quality care in accordance with applicable state and federal laws, regulations, and guidelines. The nurse reviews medical records and cases for quality of care, appropriate service levels, medical management, and cost containment; assists with service authorizations; verifies and updates insurance information; analyzes audit findings; and participates in treatment planning and utilization management. The position may require travel. Applicants must hold a Connecticut Registered Nurse license or a multistate or compact Registered Nurse license. A comprehensive medical examination, including drug screening, is required after a conditional offer.

Requirements

Three years of experience as a Registered Nurse.
At least one year of the required RN experience must be in hospital or institutional nursing, a medical treatment facility, rehabilitative or occupational nursing, or medical review of insurance claims.
Must possess and retain a Connecticut Registered Nurse license or hold a Multistate or Compact Registered Nurse license.
Considerable knowledge of nursing principles, practices, and current trends.
Knowledge of and ability to apply relevant state and federal laws, statutes, and regulations; standards of practice in medicine, nursing, and other health care disciplines; and regulations and standards pertaining to utilization review.
Interpersonal skills and oral and written communication skills.
Ability to analyze patient profiles and progress charts to evaluate proper care and treatment.
May be required to travel.

Nice To Haves

Experience with reimbursement of healthcare services.
Experience and knowledge of insurance verification tools.
Experience with state and federal regulations and standards related to utilization review.
A bachelor's degree in nursing may be substituted for one year of the general experience requirement.

Responsibilities

Assess, evaluate, and audit medical records to ensure quality of care and verify that clients meet the appropriate level of care.
Apply relevant federal and state statutes, regulations, guidelines, and standards in daily work.
Assist with authorization of services for Medicare, Medicaid, and private insurance companies.
Perform insurance verification using tools such as Inovalon, CTDSS, AP, and NGS Connex.
Update insurance information using the WITS system.
Summarize and analyze audit findings and report needed corrections to appropriate disciplines.
Participate in treatment team meetings to ensure each client's plan of care reflects identified needs.
Apply knowledge of billing and coding for services provided.
Monitor and update the Utilization Management Plan and chair the Utilization Management Committee.
Conduct case reviews for quality and appropriate medical management, cost containment, peer review, and rehabilitation.
Prepare statistical reports and implement program decisions based on revisions in standards.
Maintain current knowledge of relevant discipline changes and attend professional workshops, seminars, and in-service training.
Monitor personal injuries and medical costs to evaluate the need for services billed for appropriate injuries.
Perform related duties as required.