Utilization Management Registered Nurse RN

Trinity Health; Hartford (CT); Hybrid; USD 85,000 - 110,000; Full time

Job summary

Saint Francis Hospital in Connecticut is seeking an Utilization Management (UM) Registered Nurse to review services and treatment plans, ensuring high quality, cost-effective patient care. Using InterQual and Milliman guidelines, you’ll collaborate with providers and care teams to support optimal health outcomes.

The role requires an accredited nursing graduate with CT RN license; BSN preferred; 3+ years in utilization management or case management in acute care.

Qualifications

• Graduate of an accredited School of Nursing.
• Current, unrestricted Connecticut RN license.
• BSN preferred; RN with BSN encouraged to apply.
• 3+ years of Utilization Management, Utilization Review, Case Management, or related experience in an acute care hospital.
• Experience using InterQual and/or Milliman clinical criteria.

Responsibilities

• Conduct concurrent utilization reviews to determine appropriate level of care using established criteria.
• Initiate, manage, and track admission authorizations and payer communications.
• Review and monitor insurance denials and support appeals processes.
• Collaborate with physicians, case managers, and interdisciplinary care teams to optimize care plans and discharge planning.
• Ensure documentation reflects severity of illness, medical necessity, and resource utilization.
• Partner with Finance, HIM, Admitting, and other departments to support utilization management activities.
• Work with care coordination teams to promote high-quality, cost-effective outcomes.
• Maintain compliance with regulatory, accreditation, and payer requirements.

Skills

Utilization Management

Case Management

InterQual/Milliman criteria

Interdisciplinary collaboration

Education

BSN preferred

Bachelor of Science in Nursing

Tools

EMR systems

Job description

Employment Type: Full time Shift: Day Shift

Position Summary

The Utilization Management (UM) Registered Nurse is responsible for reviewing medical services and treatment plans to ensure the delivery of appropriate, cost-effective, and high-quality patient care. Using established clinical guidelines, regulatory requirements, and health plan policies, the UM RN collaborates with providers, interdisciplinary care teams, and patients to support optimal health outcomes while promoting the efficient use of healthcare resources.

Key Responsibilities

• Conduct concurrent utilization reviews to determine and validate the appropriate level of care using established criteria, including InterQual and Milliman guidelines.
• Initiate, manage, and track admission authorizations and payer communications.
• Review and monitor insurance denials, support appeals processes, and identify opportunities for utilization management process improvements.
• Collaborate with physicians, case managers, and interdisciplinary care teams to optimize care plans and facilitate timely, effective discharge planning.
• Ensure clinical documentation accurately reflects severity of illness, medical necessity, and appropriate resource utilization.
• Partner with Finance, Health Information Management (HIM), Admitting, and other key departments to support utilization management activities and organizational goals.
• Work closely with care coordination teams to promote high-quality, patient-centered, and cost-effective outcomes.
• Maintain compliance with regulatory, accreditation, and payer requirements.

Minimum Qualifications

Required

• Graduate of an accredited School of Nursing.
• Current, unrestricted Connecticut Registered Nurse (RN) license.

Preferred

• Bachelor of Science in Nursing (BSN).
• Three (3) or more years of Utilization Management, Utilization Review, Case Management, or related experience in an acute care hospital setting.
• Experience utilizing InterQual and/or Milliman clinical criteria.

Position Highlights

• Full-time, 40 hours per week
• Hybrid work schedule

About Saint Francis Hospital

Saint Francis Hospital has been a trusted healthcare leader in Connecticut since 1897. As a member of Trinity Health Of New England and Trinity Health, one of the nation's largest Catholic healthcare systems, Saint Francis is committed to delivering exceptional patient care, advancing medical innovation, and serving the community. Saint Francis Hospital is a 617-bed Level I Trauma Center and major teaching hospital offering a comprehensive range of specialized services. Notable programs and affiliated entities include the Comprehensive Women’s Health Center, the Connecticut Joint Replacement Institute, and Smilow Cancer Hospital. Through a commitment to excellence, compassion, and innovation, Saint Francis continues to provide high-quality care to patients across the region.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.