Pediatric Utilization Review Nurse – Care Coordination

Connecticut Children's Medical Center; Hartford (CT); On-site; USD 85,000 - 110,000; Full time

Job summary

Connecticut Children’s Center for Care Coordination (The Center) is seeking an Utilization Review (UR) Nurse with strong clinical skills and a focus on medical necessity determinations. You will utilize InterQual and Milliman Care Guidelines, perform concurrent and retrospective reviews, and support the UM program with efficient processes and outcome reporting.

The role requires a BSN, CT RN licensure, and at least 3 years of nursing experience.

Qualifications

• BSN required; CT RN licensure required
• Minimum 3 years nursing experience in healthcare
• Pediatric UR/case management or discharge planning experience preferred
• Knowledge of InterQual and Milliman guidelines and medical record documentation requirements

Responsibilities

• Performs chart reviews to assess quality, timeliness, and appropriateness of patient care.
• Conducts hospitalization reviews for Medicaid and other payers using CMS guidelines and criteria.
• Maintains documentation in UR software and supports UM program metrics.
• Collaborates with care teams and leadership; participates in UM committee activities.
• Provides consultation to physicians on documentation needed to justify level of care.

Skills

Utilization management

Medical record review

InterQual criteria

CMS guidelines

EPIC familiarity

Communication skills

Education

BSN

CT RN License

Tools

EPIC experience

Job description

Connecticut Children’s Center for Care Coordination (The Center) is seeking an Utilization Review (UR) Nurse with strong clinical skills and a focus on medical necessity determinations. You will utilize InterQual and Milliman Care Guidelines, perform concurrent and retrospective reviews, and support the UM program with efficient processes and outcome reporting.

The role requires a BSN, CT RN licensure, and at least 3 years of nursing experience.