Remote Pediatric Utilization Review Nurse

Connecticut Children's; Hartford (CT); Remote; USD 75,000 - 110,000; Full time

Benefits offered by this job

Medical, dental and vision insurance

Hospital paid life and disability

Retirement savings plan with hospital

Job summary

Connecticut Children’s Center for Care Coordination (The Center) integrates care coordination through innovative programs, providing technical assistance and building partnerships to strengthen families and communities.

The Utilization Management Nurse supports the UM program with medical necessity determinations, using InterQual/Milliman guidelines, and reviews medical records to ensure compliant hospitalization statuses across payers.

Qualifications

• BSN required; 3 years nursing experience in healthcare.
• Knowledge of medical care criteria and utilization review.
• Proficiency with EPIC and MS Office; strong documentation skills.
• Case management certification preferred.

Responsibilities

• Perform chart reviews to assess quality, timeliness, and appropriateness of patient care.
• Conduct hospitalization reviews for Medicaid and other payers using guidelines.
• Perform concurrent and retrospective clinical reviews to support utilization management.
• Maintain documentation in Utilization software and track resource use.
• Educate physicians on documentation to support level of care.
• Collaborate with care team to optimize utilization of hospital resources.

Skills

Clinical nursing

Analytical thinking

Communication skills

Education

Bachelor of Science in Nursing (BSN)

Case Management Certification (preferred)

Tools

EPIC

Microsoft Word

Excel

Job description

Connecticut Children’s Center for Care Coordination (The Center) integrates care coordination through innovative programs, providing technical assistance and building partnerships to strengthen families and communities.

The Utilization Management Nurse supports the UM program with medical necessity determinations, using InterQual/Milliman guidelines, and reviews medical records to ensure compliant hospitalization statuses across payers.