Pediatric Utilization Review Nurse

Connecticut Children's Medical Center; United States; Remote; USD 90,000 - 120,000; Full time

Job summary

Connecticut Children's Medical Center is seeking a licensed RN for Utilization Management within the Center for Care Coordination. The UR Nurse conducts concurrent and retrospective reviews to determine medical necessity, using InterQual and Milliman guidelines, and collaborates with payers and care teams to optimize care and resource use.

Candidates should have a BSN and at least three years of nursing experience, with knowledge of CMS guidelines and EPIC.

Qualifications

• BSN required.
• 3 years nursing experience in a healthcare setting.
• Pediatric nursing experience preferred.
• UR, case management or discharge planning experience preferred.
• Current CT RN license required or nurse licensure compact (NLC).
• Case Management Certification preferred.

Responsibilities

• Performs chart review to identify quality, timeliness, and appropriateness of patient care.
• Conducts hospitalization reviews for Medicaid and other payers based on guidelines.
• Gathers clinical information for continued stay utilization review with payers.
• Escalates cases for secondary review as needed.
• Adheres to CMS guidelines for utilization reviews and supports discharge planning to reduce LOS.
• Maintains documentation in UM software for each patient’s resource utilization.
• Provides consultation to physicians on documentation to support level of care.

Skills

Care coordination

Clinical judgment

Medical record review

Communication skills

Team collaboration

Education

Bachelor of Science in Nursing (BSN)

3 years nursing experience in healthcare setting

Tools

EPIC

MS Word

MS Excel

MS Access

Job description

Connecticut Children's Medical Center is seeking a licensed RN for Utilization Management within the Center for Care Coordination. The UR Nurse conducts concurrent and retrospective reviews to determine medical necessity, using InterQual and Milliman guidelines, and collaborates with payers and care teams to optimize care and resource use.

Candidates should have a BSN and at least three years of nursing experience, with knowledge of CMS guidelines and EPIC.