Utilization Review Nurse- 20hr

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.
 

• 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. Uses these criteria to screen for appropriateness of level of care based on medical record documentation.
• 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 verses out-of-network benefits and communicates data to the patient and healthcare team as indicated

Position Specific Responsibilities:

• 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.
• Ability to apply industry accepted level of care criteria while utilizing clinical critic