[Hiring] Utilization Review Nurse @Connecticut Children's

Role Description

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.

Responsibilities

• 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.
• 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 versus 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 critical thinking skills to advocate for appropriate utilization of hospital resources.
• Demonstrated ability to be self-directed, organized, diplomatic and team-oriented.
• Facilitate effective communication within the health care team to promote continuity of care.
• Skilled in the operation of computer systems including proficiency in Microsoft Office applications Word, Excel and Access.
• Demonstrates support for the mission, values and goals of the organization through behaviors that are consistent with the Connecticut Children’s standards.
• Ability to prioritize and manage multiple tasks.
• Demonstrated written and verbal communications skills.

Qualifications

• Education: Bachelor of Science in Nursing (BSN).
• Experience: 3 years’ nursing in a healthcare setting.
• Pediatric nursing experience (preferred).
• Previous experience in Utilization Review (preferred).
• Previous experience in Case Management or Discharge planning (preferred).
• Current State of Connecticut Registered Nurse Licensure required or nurse licensure compact (NLC) and maintained thereafter.
• Case Management Certification (preferred).

Knowledge, Skills, and Abilities

• Demonstrate working knowledge of how to interpret and apply medical care criteria.
• Knowledge of community resources, treatment options, home health availability, funding options and special programs.
• Coordinates management of care for a specified patient population; follows patients throughout the continuum of care and ensures optimum utilization of resources, service delivery and compliance with hospital standards.
• Provides ongoing support and expertise through comprehensive assessment, care planning, plan implementation and overall evaluation of individual patient needs.
• Self-directed/motivated, organized, diplomatic and team-oriented.
• Function in a high energy, fast moving environment.
• Maintain flexibility as determined by acuity of medical unit.
• Prioritize case load.
• Collaborate with various disciplines.
• Communicate effectively and efficiently.
• Excellent written and verbal communication skills.

Benefits

• Comprehensive compensation and benefits package for eligible team members, including medical, dental and vision insurance.
• Hospital paid life and disability coverage.
• Paid time off and leave programs.
• Education and training assistance.
• Retirement savings plan with hospital match.
• Employment assistance program.