Utilization Review Nurse

This is a fully remote position, open to applicants in Connecticut.

📋 Description

• Conduct thorough chart evaluations to determine quality, timeliness, appropriateness, and level of care.

• Execute hospitalization assessments for Medicaid, various insurers, and self-pay patients according to established guidelines.

• Collect clinical data for continued-stay utilization reviews in collaboration with payers.

• Refer cases for secondary review when deemed necessary.

• Carry out both concurrent and retrospective clinical assessments while adhering to regulations, policies, and timelines.

• Follow CMS utilization-review guidelines diligently.

• Formulate and implement strategies aimed at reducing length of stay and resource usage in partnership with discharge-planning staff.

• Recognize and document barriers to the progression of care, preventable days, and delays.

• Work closely with hospital case management and care teams to optimize resource utilization.

• Represent Utilization Management in committees as required.

• Maintain documentation in utilization software for each patient.

• Educate physicians and qualified practitioners on the documentation required to support the ordered level of care.

• Provide reimbursement information and confirm both in-network and out-of-network benefits.

• Stay updated on regulatory changes and national as well as local coverage determinations.

• Advocate for evidence-based protocols and order sets.

• Utilize level-of-care criteria and clinical critical thinking to promote appropriate resource utilization.

• Collaborate with The Center team to ensure suitable care settings and timing.

• Identify gaps in care and resources while addressing access issues.

• Act as a change agent, advocate, and resource person in support of performance-improvement initiatives.

• Assist the hospital’s Utilization Management Committee and provide key metrics to leadership upon request.

⛳️ Requirements

• Bachelor of Science in Nursing (BSN).

• Minimum of 3 years nursing experience in a healthcare environment.

• Current licensure as a Registered Nurse in the State of Connecticut or nurse licensure compact (NLC), maintained thereafter.

• Strong understanding of medical care criteria interpretation and application.

• Familiarity with community resources, treatment options, home health availability, funding opportunities, and special programs.

• Proficient in Microsoft Office Word.

• Capable of utilizing and updating Excel spreadsheets.

• Ability to navigate the EPIC system.

• Competent in functioning within a dynamic, fast-paced environment.

• Flexible and adaptable based on the medical unit's acuity.

• Skilled in prioritizing caseloads and managing multiple responsibilities.

• Ability to collaborate effectively across various disciplines.

• Excellent written and verbal communication skills.

• Experience in pediatric nursing is preferred.

• Prior experience in Utilization Review is preferred.

• Previous Case Management or Discharge Planning experience is preferred.

• Case Management Certification is preferred.

🏝️ Benefits

• Medical insurance.

• Dental insurance.

• Vision insurance.

• Life insurance provided by the hospital.

• Disability coverage at no cost to the employee.

• Paid time off.

• Various leave programs.

• Assistance with education and training.

• Retirement savings plan with hospital matching contributions.

• Employment assistance program.